Reentry Planning

HOW

See the MOMCARE Preparing for Reentry Checklist for Pregnant & Postpartum Patients to assess their health and resource needs with special consideration for OUD.

What general considerations should jail staff address during reentry for pregnant and postpartum patients?

• Reentry planning begins at intake. Assess reentry needs as soon as possible given the unpredictability of release timing. 
• Compile a list of local resources in the following areas: prenatal care providers, addiction treatment facilities accepting pregnant patients, housing resources for pregnant individuals and those with children, WIC, domestic violence support, and other community resources for pregnant individuals as appropriate.
• Contact the organization/entity to establish a contact person.
• Compile a reentry resource guide (and update it as needed). It should include community organizations that address reentry needs with information on their provided services, and a contact/point person.
• Enlist the assistance of community supervision staff (probation/parole) as needed.
• Provide the patient and the person picking them up with a naloxone (“Narcan”) kit at the time of release.
• Provide the patient and the person picking them up with a copy of the urgent maternal warning signs flyer.
• Organize weekly multidisciplinary team (MDT) meetings with community agencies and organizations to discuss pregnant and postpartum patients in jail before and after release. MDT meetings help ensure cross-collaboration and information-sharing about the patient’s individualized needs and whether the patient accessed services. MDT members can include custody supervisors, jail medical leadership, recovery community organizations, the health department, the police department, etc.

What are the reentry steps to ensure MOUD continuation?

• Create a list of local options of drug treatment programs or buprenorphine providers that accept pregnant patients. 
• If on buprenorphine: Provide a 2-week supply of doses to bridge them until they can get to a community provider. Also, provide a prescription for the next dose. 
• If on methadone: If your jail stocks methadone, then you can provide patients with a 3-day supply of doses to bridge them until they can get to an OTP. See this brief for details.
• Ensure that patient has a place to get their methadone or buprenorphine in the community and has transportation to get their first dose on the day of release.
• Consider designating someone as a “patient navigator” to follow the patient after release to help them get their first dose in the community. 
• Make a plan with the pregnant patient about continuing MOUD, and make sure they have contact information and hours for community-based programs. 
• Make a “warm hand-off” connection to the program before the patient leaves jail, and communicate with the program/provider once the patient has left.
• A warm hand-off includes setting up an appointment and arranging a meeting or conversation with program staff before discharge. If possible, facilitate a hot hand-off by transporting the patient directly to the program at discharge. 

What prenatal/medical care do pregnant and postpartum patients need at reentry?

• Help patients determine where they will continue with prenatal care in the community. Place a written copy of that clinic information in the patient’s property. This is especially important if they get released before you can schedule a community prenatal appointment. 
• When the release date is known ahead of time, schedule the patient’s next prenatal appointment for them. Place a written copy of the appointment time in the patient’s property. 
• If the patient is on any medications, supply at least 2 weeks’ worth of bridge doses, and a prescription for ongoing doses. 
• Place a written copy of the patient’s medical record, including medications, in their property. 

What if the pregnant/postpartum patient does not have health insurance in the community?

Start a Medicaid application for the pregnant patient when they enter custody so that it is ready to be activated upon release. 

• Most pregnant individuals who are leaving jail will be eligible for Medicaid.
• Many states have expanded Medicaid coverage for 1 year postpartum, so you can also enroll postpartum patients in Medicaid in preparation for release.
• In 2023, Medicaid released new guidance to expand Medicaid coverage to incarcerated individuals who are within 90 days of release. Your state may have applied for this 1115b waiver opportunity and if so, you can enroll patients in Medicaid while they are in jail!
• If your state has not been granted an 1115b waiver, the current policy doesn’t allow Medicaid coverage for currently incarcerated individuals, but you can still facilitate Medicaid enrollment before release.

What social needs do pregnant and postpartum patients have at reentry?

• Assess the patient’s resource needs including housing (if need housing, make sure they accept pregnant individuals), transportation, health insurance, employment (job training and education), food security via WIC, legal aid, childcare and parenting classes, peer recovery support, reestablishing familial relationships and family reunification. 
  • Set up a WIC appointment before the patient leaves custody. 
• Use the MOMCARE Preparing for Reentry Checklist for Pregnant and Postpartum Patients with special considerations for OUD to assess the individual’s needs.
  • Identify the current state of challenge and patients’ desires/goals for each.
  • Items identified as needs require a follow-up action item from a staff member.
• Counsel and plan with the patient
  • Discuss best- and worst-case scenarios of what will happen in the hours, days, and weeks after release.
  • Create a plan to overcome challenges and figure out how to stay on track. Write down a plan together and give the patient a copy at discharge. The plan may include: what/who to avoid, and who to contact/where to go if you need help
• If the patient is transitioning to a residential treatment facility, the jail should coordinate with the treatment facility to facilitate a smooth handoff (i.e., transportation, timing).
• Find out whether your state (or county) helps incarcerated/recently released individuals get state identification for reentry—if so, assist them in getting an ID.
• Consider creating a “community reentry identification card” for your county

WHY 

Why is reentry planning important for pregnant and postpartum individuals who use opioids?

• Pregnant and postpartum patients have unique and time-sensitive health care and resource needs. Reentry planning is critical to ensure they are connected to health care and other resources in the community. 
• The risk of overdose death within 2 weeks of jail release is very high for people with OUD, especially for pregnant and postpartum individuals. Continuing MOUD in the community reduces that risk.
• Comprehensive reentry planning facilitates ongoing medical care and can help prevent recidivism and return to use.

• Reentry guidance
  • MOMCARE Preparing for Reentry Checklist for Pregnant and Postpartum Patients- MOMCARE developed this checklist that can be used to guide reentry planning specifically for pregnant and postpartum individuals with OUD.
  • After Incarceration: A Guide to Helping- This guide provides an overview of topics and resources for serving women who are reentering the community after a period of incarceration. It is intended to increase knowledge of specific issues that women often face during reentry and to provide relevant resources to providers who can help them succeed.
  • 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. 
  • Guidelines for Successful Transition of People with Mental or Substance Use Disorders from Jail and Prison: Implementation Guide-  Provides behavioral health, correctional, and community stakeholders with examples of the implementation of successful strategies for transitioning people into the community.
  • Recommended Practices for Implementation and Expansion of Jail-Based Naloxone Distribution Programs- Details what naloxone is, addresses safety/liability concerns, and details distribution efforts with training videos, instructional guides, and strategies for distribution. Scroll down to the bottom of the web page for the section “Strategies for Naloxone Distribution” for practical tips. 
  • Sharing of Patient Health Records Upon Release From Incarceration–  Details how correctional facilities should provide outgoing patients with/ portable health records to help ensure continuity and prevent duplication of services
  • Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)- Information on WIC eligibility and how to apply.
• MOUD continuation
  • SAMHSA Buprenorphine Practitioner Locator–  List of practitioners authorized to treat opioid dependency with buprenorphine by state (list and map options).
  • SAMHSA Opioid Treatment Program Directory- Lists Opioid Treatment Programs by state with name, DBA, street, city, zip code, phone, certification, and map
• Reentry programs
  • Family-Based Residential Treatment– a national directory of residential substance use disorder treatment programs for parents with children
  • The National Reentry Resource Center (NRRC) maintains a directory of all current Second Chance Act grantees around the country and has compiled a comprehensive reentry grant profile for each state
• Patient education materials
  • Urgent maternal warning signs-  English flyer with information on urgent maternal warning signs to look out for; this site has the flyer in 39 languages
  • MOMCARE Treatment for OUD during Pregnancy and Postpartum patient education 1-pager
• Medicaid Coverage
  • Medicaid and CHIP Eligibility for Pregnant Women– Details eligibility requirements, federal statutory and regulatory requirements, and state plan options
  • Medicaid Postpartum Eligibility- This page tracks which states have extended Medicaid coverage to be 1 year postpartum.
  • HHS New Medicaid Reentry Section 1115 Demonstration Opportunity to Increase Health Care for People Leaving Carceral Facilities- New guidance can help people at high risk of substance use disorders and other health conditions get the care they need, especially as they transition from incarceration back to the community.
  • State Policies Connecting Justice-Involved Populations to Medicaid Coverage and Care- States may take other steps to leverage Medicaid to improve continuity care for justice-involved individuals, large health disparities seen during COVID, looking at care for post-release
• Identification cards
  • Fact sheet on facilitating identification for re-entry. Discusses access to state identification, provision of identification pre- and post-release, “lessons” learned from CA, FL, and TX, and offers implementation considerations.
  • Example from Montgomery County, MD of Re-entry Services Unit facilitating ID cards. Discusses opportunity to gain Community Reentry Identification Cards in Montgomery County, MD post-release that can be used for legal photo identification, RIDE ON bus transit pass in Montgomery County, Library Card for computer and services access at all Montgomery Country Public Library Branches
• Research on the increased risk of maternal overdose
  • Maternal and infant characteristics associated with maternal opioid overdose in the year following delivery- Study on women who delivered 1+ live births, Looking at postpartum opioid overdose 46.6% had OUD diagnosis w/i 12 months before delivery.
  • Mortality after Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends from 1999 to 2009- Cohort study on the prison system of WA State DoC, Overdose leading cause of overdose deaths post-release, Women at an increased risk.