Transitions Clinic Network Programs
Improving Access to and Engagement into Care upon Release from Incarceration
Overdose, SAMHSA indicates, is the “leading cause of death among formerly incarcerated individuals.”1 A study in Washington State found that people’s mortality rate in the two weeks after release from incarceration was 12.7 times higher than the rate for other people in the state. Their rate of overdose was 129 times higher than other residents’.2
Access to medications for opioid use disorder (MOUD) during incarceration lowers the risk of opioid mortality after release.3 When Rhode Island’s Department of Corrections implemented an MOUD program, overdose deaths after incarceration declined by 60.5 percent.4 MOUD in jail or prison and upon release is a CDC-recommended evidence-based strategy to prevent opioid overdose.
Given the dangers of withdrawal and return to use, it is important that patients continue their MOUD upon release and that a “warm handoff” to treatment is provided.5 Since not all prisons and jails offer MOUD,6 some people with OUD will have experienced withdrawal during incarceration. A handoff that ensures access to MOUD, along with linkage to transitional housing and other supports, is important for these patients as well. They will have a lowered tolerance that puts them at greater risk for overdose. To save lives at a time of heightened risk, the CDC also recommends naloxone distribution programs for people leaving criminal justice settings.7
With social isolation and other hardships during the COVID-19 pandemic leading to more overdose deaths,8 these measures are all the more critical.
so welcome to our presentation this is the ur medicine recovery center of excellence and we're very pleased today to tell you about the transition clinic network programs and how that relates to improving access to medication for opioid use disorder and other treatments that are needed upon release from incarceration in case you're not familiar with us we are the ur medicine recovery center of excellence which was established in 2019 by the health uh resources and services administration or hersa uh our aim has been to reduce morbidity and mortality related to substance use disorder particularly focusing on synthetic opioids and our goal is to disseminate best practices which have been specifically adapted for rural communities and we are aiming to address the needs specifically of 23 counties in appalachian ohio kentucky west virginia and new york but our program also provides assistance to rural communities throughout the u.s
i am diane morse i'm an associate professor of psychiatry and medicine and i practice and teach internal medicine and do research related to it i have a program called the women's initiative supporting health transitions clinic which is part of the transitions clinic network which we started in 2012. hi good morning everyone i'm shira shavit i'm a family physician and faculty at the university of california in san francisco and i'm also the executive director of the transitions clinic network so the transitions clinic network programs have been grounded in addressing the health risks for formerly incarcerated individuals in that group we know that overdose is the leading cause of death upon release and after release the risk of dying from an opioid overdose is 10 to 40 times higher among people who are recently released from incarceration compared to the general population for example one washington state study showed that actually mortality rates in the first two weeks after release are very high 12.7
almost 13 times higher than the general population in that state and among that group drug overdose was the leading cause of mortality uh that actually was 129 times higher rate of overdose than other state residents other leading causes are also very concerning and really highlight the needs of this population cardiovascular disease homicide suicide as well as cancer and motor vehicle accidents and then other risks other medical health concerns are hepatitis c and hiv one problem in addressing these problems these concerns is that people are generally released with little to no medication there are many challenges to transitioning from incarceration for people who are formerly incarcerated or recently incarcerated some of these risks include access to health care which is part of what we want to address specifically in the transitions clinic but that also includes access to behavioral health as well as substance use disorder treatment and that can also be done in primary care as we'll discuss another issue is access to safe and stable housing which is one of the social determinants of health another social determinant of health is food insecurity lack of employment or health or employment barriers and trauma is an enormous challenge also people who are released face challenges with parental rights as well as child care and then navigating all these and other services in the community and we're going to talk about how this program helps those another challenge in rural communities is the growing population that are impacted so jail populations in rural communities have increased and people consequently are returning to those communities along with employment and housing though people with opioid disorder opioid use disorder face specific challenges one of which is limited availability of non-stigmatizing and thorough health services including access to medication for opioid use disorder which we know is life-saving we also know that people have a lot of difficulty with particularly rural communities with distance and transportation including to health services um there is quite a bit of stigma and there can be difficulty because people tend to know each other again particularly common in rural communities and stigma we know has a negative impact on health care because it impacts people's access to treatment both on their side and on the health service side another challenge is is that we have limited access to medication for opioid use disorder in jails actually as well as prisons and this varies across the u.s
depending on what community you're living in it can vary from county to county in a single state there's limited access to maintenance medication or opioid use disorder both in a substance use disorder programs and in primary care and this can be again a particular difficulty in rural communities so one really helpful approach then is to have a primary care provider that can prescribe the medication for opioid use disorder and this is something that is often the case in the transitions clinic network programs um however primary care providers need support in order to provide that we know that
medication for opioid use disorder saves lives one way in which it saves lives is to use naloxone and these are this can be provided both in the community at large as well as in the criminal justice setting including jail probation parole prisons because we know that people can use opioids and experience overdoses in these settings another thing that we know saves lives as i said before as a medication for opioid use disorder but particularly use of it during incarceration in fact when the rhode island department of corrections implemented medication for opioid use disorder in jail in their
jail prison combination program they actually decreased mortality after release by over 60 percent so that's really significant um if people do not have moud or medication for opioid use disorder upon release they can actually face much higher risks as i mentioned in the very beginning of opioid overdose part of that is because if they don't have the medication they have a lower tolerance so they may be released and then use the same amount that they were using before and unfortunately die from that not only that but they've gone through the trauma of withdrawal during incarceration and that
can set them up for wanting to go back out and use upon release if they do not have linkage to care during incarceration and then set up for them after release again this can set people up for use and overdose so our what has been successful is to have community programs which help to engage people prior to release so that when they leave they're ready to start treatment we like to offer them choices and it's not always possible but as much as possible we offer them choices of the substance use program or primary care and other options in between and in our program having a warm handoff where
the transitions clinic program starts to engage people prior to release from incarceration has been most successful thanks diane for that wonderful overview as i mentioned before i'm sure shaving i'm a family physician and i also see patients in the primary care setting and i want to talk to you more today about the transitions clinic program which we developed in 2006 in san francisco and you know this really came out of our own experience in trying to care for these very complex patients with uh opiate use disorder and other substance use disorders who are also contending with chronic
conditions as well as trying to address all of their social determinants of health upon reentry and so i'm really excited to talk to you more about that program how we developed it and what it looks like um sort of since we started in 2006 uh we've developed this program we found a strong evidence base for doing this work and have since disseminated the model of care to over 48 different primary care clinics in 14 states and puerto rico including diane's wonderful model which she's taken with and really run with and iterated in new york so um you're going to hear more about this program some
of the key components are that these are all primary care clinics these are existing clinics in communities that see people returning from incarceration and all of these clinics hire community health workers who have lived experience of incarceration and embed them within their primary care teams and our organization which is a non-profit supports the development of these programs and clinics kind of from start to finish ensuring i'm helping the clinics assess what their needs are what kind of training and assistance they may need in implementing this type of program helping them build the
necessary relationships in the community as well as thinking about ways to sustain these types of programs moving forward so as i mentioned the transitions clinic program is a primary care based program right this is done in existing clinics because as you heard from dr morris people returning home are very high risk of death upon return and a drug overdose is one of the kind of most pressing reasons people die when they first return home but also things like cardiovascular disease and suicide and you know cancer so we know that additionally care for their chronic conditions is really
important in this post release time period and that primary care clinics play a really important role in the community for caring for these individuals and yet sometimes in our own clinics we struggle to really provide the full breadth of services people may need including addressing substance use disorders mental health conditions and all of the social determinants of health and this is why we created the transitions clinic program is to support the primary care systems in leveraging the services they have and developing new services to better meet the needs of these individuals returning
home from incarceration so before i move on to the next slide i just want to take a minute to talk a little bit of the importance of why we hire community health workers with lived experience of incarceration and so i think when you're thinking about this rising number of people who have a history of substance use disorder who are being impacted by the criminal justice system it's important to realize that with that experience of incarceration comes a lot of shame and stigma and discrimination in the community when people return from incarceration while people are incarcerated they may
experience negative experiences with the health system that may color their uh connect wanting to connect with health services in the community if they weren't treated well during incarceration or if they are experiencing discrimination in the community because of their substance use disorder they may not feel comfortable in accessing health care services and in fact there was a study that demonstrated that when people identify themselves to primary care clinics as having a history of incarceration they were less likely to get appointments in that clinic so it's really important with this
model of care that there are people who are working as part of the medical team who are based within the clinic who understand that experience who have that shared experience it could really support people and feeling comfortable in accessing services for feeling they can build trust with the health system and feel that they're not going to be discriminated against and that if they have needs that they need to communicate they have sort of a trusted partner in the health team to support them i think another piece that's really important related to this is that people are also systemically
excluded from jobs in the healthcare system system because of their history of incarceration and by creating workforce opportunities for people who have been incarcerated who have substance use disorders our health systems are also reversing that discrimination that people face because of their past incarceration so for these reasons this is a really core element to the model this is really what we call our special sauce and what makes this work so impactful so you know what does this program look like as i mentioned really the core of the program is adding another team member and that's a
community health worker who has a lived experience of incarceration and that community health worker really connects with the individual even before they come to the clinic ideally they're connecting with people in the incarcerated setting in jail or prison or once they've been released in the probation and parole department in other places in the community you know could be through faith-based communities could be from patients families referring you know really anywhere you might see somebody who's coming out of incarceration and these community health workers really play an important role
in the team in that they help patients navigate complex medical systems as well as the social services in the community so they really help people in getting into the clinic feeling comfortable and safe in that environment and then also helping people connect to all of the re-entry needs they need to stay healthy and to thrive in the community post incarceration um i think you know adding this community health worker is a really wonderful addition to the team and is able to do um you know support patients in ways that you know as a bbc clinician you may not be able to do that you may not have
other staff on your team that can go out into the community and look for people at the probation office for instance or who can go into the jail or make those relationships in the community to really support patients so that community health worker is this really wonderful flexible position but also somebody who because of their lived experience really can create a trusting relationship with the patient and help them feel comfortable in accessing services in the primary care setting so um you know this is kind of what the model of enhanced care looks like in the transitions clinic network and
so you know first thing when we work with clinics you know we really look at this model of care how do you embed a community health worker into your team that may be new for some sites some sites may have some experience in doing that and thinking about how does the team work together what are the roles of each team member and then how do you leverage the supports and value of the community health worker not just in the navigation across systems but also as this cultural interpreter or somebody who understands the experience of the patient and is able to communicate that effectively to the
team and vice versa in really helping patients uh communicate with their healthcare providers understand their treatment plans as well as you know effectively engage in services um additionally um what we see in these primary care clinics is working to improve mental health services for patients because we know there are high rates of mental health conditions and people who are incarcerated as well as building out primary care substance use treatment services like moud as diane was explaining i'm also addressing some of the other health needs people may have like treating hiv and hepatitis c
having trauma-informed care you know addressing some of the trauma that people may have experienced before incarceration or during incarceration um and then in bringing into the the community to better understand what are the needs of this patient so thinking about what are ways to improve services within the clinic structure things that better meet the needs of the patients i think one example that often comes up for our clinics is the 15-minute late policy um you can imagine somebody who just got out of prison or jail who maybe doesn't know the community as well or has difficulty navigating
may not make it in time for their their visit and they may be more than 15 minutes late and if they come late and are told no you have to come back another day sometimes that feels really punitive and it actually can kind of reflect their experience in prison or jail and that may be a turn off and people may not want to come back to the clinic so we work with the clinics to think about ways of ensuring that people's needs are met and they feel like they're supported in that environment um other things we do in the clinic is helping them build relationships with these other systems that they
don't traditionally work with like the criminal justice system so prisons and jails probation and parole the community health worker works closely with these entities meeting people pre-release advocating on behalf of their clients um to the probation and parole officers um and really allowing sort of for some um improved communications and we also work with the sites to help them build these relationships and think of ways more systematically to connect so for instance um some of our sites actually utilize telemedicine to talk to people in jail pre-release and connect with nurses pre-release
and are able to get medical records so working to kind of enhance systems across the criminal justice and health system other places that we work with the sites to improve their systems are building relationships with behavioral health systems outside of primary care thinking about housing systems as well as kind of the loose network of reentry services that may exist in the community and other supports that may be provided by family or faith-based entities so it really is this opportunity for primary care clinics to kind of open their doors or their walls and be so more contiguous with other
systems that works really well for these complex patients who have so many needs across multiple systems so how well does this program work we have extensively studied our program over the years we were able to do a randomized controlled trial in san francisco looking at patients returning from state prison to san francisco patients came to our clinic and then were randomized to stay in our program or to get care per usual in our safety net system and what we found was that the transitions clinic program reduced emergency department utilization by 50 so people had 50 fewer visits in the first
year post incarceration in a subsequent propensity match study that we did in connecticut we found that our program for patients who were released from incarceration in connecticut who were going to new haven where we had our program as compared to hartford where there was no program those individuals had fewer preventable hospitalizations when they were hospitalized they spent less time during that hospitalization and they also had fewer probation and parole violations so i'm all told they spent 25 days less reincarcerated in jail for any technical violations so the program works well to
engage people into care and as you know these oftentimes these are kind of our community members that don't always engage into services and the result is that they use acute care services uh less often and that they are less likely to go back to the incarcerated settings of overall improving their reentry into the community we've also extensively studied our transitions clinic the women's initiative supporting health which is only for women in this particular iteration we found that looking at the quantitative outcomes uh 83 percent of the women that we enrolled in our program did not have a
primary care provider prior to that and uh so if we had not taken care of them they possibly very possibly would have not would not have had primary care uh looking at what kind of problems they experienced this kind of goes along with what we discussed earlier 94 of them had a mental health disorder 90 had a substance use disorder and we were able to link them with care with primary care mental health and substance use disorder treatment we also looked at some of our qualitative outcomes getting feedback from participants as well as community members and we found that the women felt
supported they felt that their choices or autonomy are being supported we enhance their health literacy by helping them access services both in the health care system and in the community you know like that whole diagram we just saw of all the community resources sometimes those resources are present but people cannot access them and our community health workers really provided that link we also gave them the kind of emotional support that made them feel comfortable and trusting that enhance their access to care and looking at just the people who had an opioid use disorder 79 percent of those
uh were able to connect with recommended treatment so just to recap people who were recently released from incarceration have very broad medical and social needs as we described primary care is an excellent way to help link people with those resources particularly enhanced by community health workers who have lived experience of incarceration we link them with evidence-based treatment for oud either by helping them access it or by providing it as a primary care provider if you are taking care of people who are formerly incarcerated you are already doing something that is wonderful but also
can be difficult and if you have the support of the transition clinic network it can help you do something you're already doing better and with less a lot less stress um our people who are involved in running this program feel that it really meets people's needs and also makes them feel a lot more comfortable taking care of them thanks dr morris i mean i think you know i just want to invite um any of you are interested in this work to reach out to our organization i think you know as i mentioned we're a network of um over 48 different primary care clinics around the country and that's really
what makes this work so rich is that everybody brings their own experience and expertise to the table every community is different and we don't pretend to be experts in your own community and what your community needs and how to best serve your patients but we do have expertise in how to link with systems how to address the complex needs of people impacting our incarceration and how to support clinics in developing sustainable models of care that meet the needs of some of the most vulnerable people in their community and so we really welcome all clinics to join um because that's really where
the learning is um in sharing across our sites nationally to learn kind of how each clinic has innovative what they've done with this kind of core evidence-based model and how they've adapted it and even grown it within their own community so please don't hesitate to reach out to us with any questions about our transitions clinic network so we would really love to hear from you as we already heard just now but um there here's some other ways you can reach out to us you can reach out by phone email website twitter linkedin and sign up for updates and as i said earlier these slides will be
available on our website but we are also available to answer questions and um we really look forward to it because until you try you don't always know what your questions are thank you very much
welcome to our presentation from UR medicine recovery center of excellence we're gonna be talking today about the transitions clinic network programs and how you could potentially implement one in your own community just to remind you the university of Rochester where UR medicine recovery center of excellence was established in 2019 funded by the health resources and services administration HRSA and our primary aim is to reduce morbidity and mortality related to substance use disorder particularly synthetic opioids today as part of a program to disseminate best practices adapted for rural communities and we are specifically aiming to address 23 counties an appellation Kentucky Ohio West Virginia and New York but also provide assistance to rural communities throughout the US I am Diane Morse I am an associate professor of medicine and psychiatry at the university of Rochester I'm an internal medicine practicing physician and researcher and I have been running our transitions clinic since 2012 after asking thanks Diane my name is Evan Ashkin I am a professor of family medicine at the university of North Carolina Chapel Hill and I am the director of the formerly incarcerated transition program which is part of the TCM network can we jump in I can describe briefly what are fit program is so we are based off the transitions clinic network and so we started off in Durham North Carolina found that the community there was probably a good place to start very progressive local government we had a highly functioning community health center that was had a mission that was very much in line with this work so that's where we began and they had a very functional reentry council as well so we already had good resources to enable our community health workers to engage with comprehensive reentry plans for our folks so we got off the ground in Durham North Carolina 2017 quickly expanded to Orange County where Chapel Hill as and then we had some success in actually wound up with a contract with our department of public safety which runs the prison system in North Carolina and through that and some other grant funding we were able to expand to 3 other counties wake county which is where Riley is Mecklenburg where Charlotte is and then in Guilford county where we have Greensboro and high point that we were able to find excellent community health center partners and all those counties work with health departments and with law enforcement as well thank you for that introduction I'm just going to reiterate a little bit what we did last time and you're welcome to watch that video I'm individuals who were recently released from incarceration have a much higher much much higher risk of overdose deaths and overdose compared to the general population combined with that they have significant barriers to accessing care to address overdose and other very significant disproportionately high health risks and this is exaggerated especially in rural areas the transitions clinic network model which both on both of us have been using both doctor ask and I have been using on solidly addresses those issues by addressing their medical problems mental health problems and in particular the substance use disorder opioid use disorder problems we have a number of evidence based practices including distribution of not can or no locks down for people as they leave criminal justice settings as well as on going light we also facilitate or provide medications for opioid use disorder during incarceration and particularly upon release which we are more directly involved in also we go do you advocate for the provision of medication for opioid use disorder during incarceration we are supported a lot by the transitions clinic network and we're gonna remind you about how you can reach out to them for that kind of support if you're interested implementing the program the transitions clinic program in primary care practice which both of us have done we're gonna just outlined some of the ways that we do it's what they call the secret sauce it requires leadership which both 7 and I've provided it definitely requires a community health worker who is a person with lived experience of incarceration it definitely requires community engagement which we can talk about how we've done we do get training and we provide training but a lot of that training comes centrally from the transitions clinic network and that's where the help comes in they also provide technical assistance and our role is really to help provide seamless care to people upon release from incarceration because the increased mortality has been shown to be particularly strong within the first few weeks after release are we really focus on actually trying to get people in within 2 weeks from release so here is an example of what our team looks like I have been the director but it doesn't necessarily have to be that physician who's the director every place is different and that's part of what's so hopeful about the transitions clinic model is that it can be suited to what works best in your particular clinic or community but there does have to be a primary care model it is a primary care model so there has to be a primary care provider and providing care for the conditions as I described the community health worker role is really the newest role they help to screen and enroll patients in the jail and in the community and they will do extensive outreach and they help people link with both medical care and social resources in the office of course the nurses and others medical assistance are crucial and that's another part of what transitions clinic provides this training for everybody we also have administrative staff who works with scheduling and communication which is actually extremely important for this population particularly with all the stigma and trauma informed approaches that are needed community health workers this this role is so important to the success of these programs are really they are what the program is about and this history of lived experience is crucial and sometimes people say well can't be someone whose work in the system or had an incarcerated family member and the answer is no it has to be someone who has this lived experience and that is what makes the program defective in Alaska many health workers to develop a quick report and trust with people are coming out of incarceration and they really need to be a member of the community I know it's in the title but sometimes people are coming in from other areas and really needs to be someone that has that local experience and networking they are integrated into the primary care clinic but they are also very much out in the community and they need to be very comfortable with the other reentry resources job training housing where you get an ID for food insecurity D.
S. asked many many community partners they need to be fluent and how to work with those folks and it's very hands on it's not referrals it's actually working with people to help them gain agency in performing these tasks and and and addressing their barriers we have done so much community engagement which includes the jails on and the other organizations I described before I would love to hear Evan describing the kind of communication that you've done yeah I think it can be illustrative the way this model works and how many stakeholders really does take to have an effective program so after undertaking Durham as an example so you know we were able to as I said got our health department actually come up with the funding for community health worker and then we embedded them into the local federally qualified health center Lincoln community health center in Durham and collaborate with a reentry council but we quickly started to realize that our clients have very high levels of opioid use disorder and in North Carolina our data is that within the first 2 weeks post release we have a 40 times the rate of overdose deaths compared to general population actually 74 times the route of heroin overdose deaths compared to general population so we knew we had to step into this area so we sat down with our stakeholders including the sheriff and the people the detention center other law enforcement the health department the health center and said we have to do better to serve this population at that point they were not continuing M.
O. U. D. for people when they were incarcerated we brought in the local mental health providers as well and we collaboratively agreed on an approach where we would take step by step progress in the detention center slash jail where we would be able to continue people on M.
O. U. D. who previously were on treatment and brought in a local your treatment program so people can actually stay on methadone as well and then after working on that program for a while we are now moving to initiating M.
O. U. D. prior to release her people had previously been not at that we identify with opioid use disorder and you know it really was a collaborative effort of the stakeholders and it was built upon some of the good will and political capital we had developed by having a fit program in the city previously and connecting people to care I really agree with that I think you know establishing those relationships is crucial building that strong positive out you know outlook so that when the sheriff and the police and courts see you coming they see you as saying yeah welcome collaborator somebody who's going to help them because they really want to help people improve their health as well another important example of engagement is working with our rural partners in North Carolina number of R.
shares come from rural and somewhat conservative communities where it could be a hard sell to provide things like medication for opioid used disorder in the jails and detention centers so it's very useful in those situations to try to have open dialogue with share or other law enforcement individuals I try to go in listening very carefully to what their priorities are and what they how they see their service to the community and almost always it's not hard to find an area where we really do have a common view of health and wellness for community members and then take that commonality to move forward with discussions of how we can better serve folks and have been successful using that tactic and then coming up with plans to move forward and taking small steps understanding that the share of maybe taking some political risks so not asking to bite off too much at one time but taking small steps that can move us toward doing better healthcare in the jails and prisons and and better treatment for Medicaid for opioid used disorder so what we're finding is a real challenge depends where you are in the country we mostly run these programs out of federally qualified health centers in many rural areas this is really the best place to run the model because the wraparound services that federally qualified health centers have with care management integrated behavioral health having a pharmacy perhaps nutrition as well and in states that have expanded Medicaid there are often opportunities to use your federal grant this can be an enabling service so there is the ability to help support the community health worker position but you oftentimes do need to be creative and maybe go to other community stakeholders in Medicaid non expansion states like we are in North Carolina it is a lot more challenging because the FQHCs we don't have the money to do this and you need to think about reaching out to health departments especially because this population of folks coming out of incarceration is really owned by nobody so the health department is a place where you can often go to find support for caring for folks but you may also look at your local hospitals as they are stakeholders and people show up after not having here to the emergency room and have expensive hospital bills they bear the brunt of that and then keeping your eye out for all kinds of federal and state funding that might support community health worker positions in your area so a community health worker can pick up a lot of the kinds of work that we might she was a physician for example this morning I had a person who's you know had insurance that wasn't covering a particular thing the community health workers spent about 20 minutes on the phone laying the foundation so that I was able to complete addressing that issue in about 5 minutes so in that way it really helps to find itself in a lot of wins so in order to do this there really has to be a collaborative spirit and what I think about it is collaborating with our regional organization so in that way it's something like our programs that are addressing substance use disorder social service organizations health department says we heard and then working with those organizations to help recruit and coordinate weren't handout so what that looks like for instance is different community health workers will go to transitional housing programs they will help people navigate court for instance they might go with them to domestic violence court to get an order of protection they might go on with them meet them at the health department to help them communicate if they need help with communicating what their needs are and making sure things are dressed so they provide that hands on help and support to navigate all the different services they might even meet them at a doctor's appointment or meet them in a lab so it really has to be flexible depending on each person's needs but as we heard a $0.7
it really also has to be building their independence so ultimately they will work with them but then help them stand on their own and then again my role is to provide the primary care but that primary care is really suited to that person's needs SO much supported by the community health worker and that primary care of course includes provision or support of chaining medication for opioid use disorder so are the transitions clinic network program helps provide the training they do it via regularly scheduled phone calls also and hot phone calls and soon meetings and really recognizing the unique needs of patients so for instance are patients who are in this program can often be late or they might come early it just depends on when they can get a ride so we are really using patient centered strategies trauma informed approaches and having people be seen when they come and that's just one example it's culturally specific in the sense that people are really interesting work housing education child care issues and that's what our community health workers are trained to help them with and also ask being non stigmatizing when people have those problems and we think a specifically about real public relations and what their challenges are and we also definitely have our staff providing support for the primary care providers in helping to provide the medication for opioid used disorder such as you know knowing about what we're doing with your talks greens have certain templates that we can do and these things are very efficient and I also just want to highlight that if you're taking care of this patient population already it can be much more efficient if you're doing it in a way where you're getting that kind of support and you have that kind of training I wanted to just for fun again what Dan was talking about with the training and unfortunate training has to be on going because there's a lot of staff turnover sadly especially in our state because our again the consequence of not expanding Medicaid R.
S. Q. 8 scenes run on very tight budgets people are well paid and they move on so it is important because the front desk staff is also key to this rate me people are coming from health care settings where they might not have gotten a lot of love and humanity and compassion and they need to be shown that day one coming in the door to feel like they can establish at that the clinic or health and you're going to work with the implementation assistance done by TCN is crucial it is I've had organizations say well you know we'll just we'll hire a community health worker you'll help us train and then you know then we've got it but you know there are so many pitfalls in so many blind spots and you know a lot of this just has to be with the fact that you know most of us in the healthcare profession do not have histories of incarceration matter of fact in the states were specifically prohibited from having that kind of licensure so we we have a large blind spots and understanding where people have come from in your challenge and so did the TCN assistance is very helpful in looking at what your resources are understanding what your clinic staff knows don't know hiring very very important issue how do you hire people who have a criminal record your HR people may tell you all you can't do that well the reality is you almost certainly can do it there are some very specific restrictions that certain states have with people with certain convictions but in general you absolutely can do it and you need to be able to and knowledgeable way push back against those discriminatory hiring policies and then understand how to head up set up your work flows how are you gonna do in reach into the prison or jail her going to work with local reentry partners to get people and because they're as Diane said in that first 2 weeks at the most vulnerable that's we need to start getting people and and it's from day one you want to think about your evaluation plan the story that you want to tell so that you can continue to get funding that you can raise visibility of this issue in the area you're working and then start again a fine people you're maybe a department of health and Human Services your health department leadership to start talking about policy changes that could help in your in your region you know one important thing is that there's a community health worker certification in your state that's very important but to get certified in a doing a background check and excluding people that have a criminal record which would impact dramatically trying to set up a C.
H. W. TCN program where none of your folks to get at state certification so that's where the policy implications are also very very important so these transitions can be very challenging and it can actually take some of the 2 weeks that we described to you know years and we really want to have people have a successful transition from incarceration to physical health mental health substance use health and also you know joining the community as a productive member of our community we also find that there are many initiatives already in place for instance here in our in my county we have an opioid task force we have a re entry task force and these both of these are multi disciplinary we have a police officer who goes to the home and reaches out for everyone who's had an overdose and he will provide them with naloxone and actually physically transport them to inpatient rehab if they want to go so we have a lot of resources in the community and it's really helpful to identify what those resources are so that you're not reinventing the wheel but more as a you know as a strong trusted partner I do find it a lot of those resources include everything except health care and so they were really excited that I wanted to you don't add health care to the mix we do warm handoffs we identify organizations that help people with their legal problems they send people to me I sent people to them similarly with transitional housing and all the substance use treatment programs so for people to know me and to know what our program is like and to be able to call or email or fax to have you know already in hand releases these things are very helpful so just to recap definitely building those connections it's very rewarding initially I was attending a lot of meetings but again trying to be time efficient having the community health worker attend a lot of those meetings that was a great transition it's a great transition for me and for the program so they are very excited to be you know put in that leadership position themselves and then they can come back and let me know what is needed and they can also let people at the meeting now what our resources are it's important to get input from the community so we want to make sure that we're hitting the target of what they want to have a dressed so periodically we will get input from them whether it's from like a lunch your resume or just going to those meetings are having a community health worker go making sure that we really get what they need raining for all the staff and transitions clinic network is invaluable and that training doctor asking do you have things you like to add to summarize I think what I'd like to bring up his 2 guiding principles that transitions clinic network has made very clear in this work very importantly one that the people closest to the problem are closest to the solutions and the voice of your community health workers really needs to help lead the work we have our community health workers as part of all of our planning leadership and evaluation teams and the other important guiding principle that we follow is nothing about us without us so we have our community devise a report as well which is made up of a lot of folks who are formerly incarcerated and really have a heart health workers be in leadership positions uplifting their stories and the stories of their they work with thanks so how can you connect with the transitions clinic network you already know how to connect with us because you're here you can go to the transitions Clinton network.org
and they have a very user friendly and informative and actually optimistic website and connect with their program manager who can help you learn more about how you can start a program such as the transitions clinic network and we're excited to hear your thoughts and questions we are actually going to be having a question answer meeting in the future and here is some more information about how you can find out about that thank you for coming we'll look forward to seeing you in the future
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Challenges in rural communities
The jail population in rural areas has increased 27% since 2013, while decreasing 18% in urban areas.9 One reason for the increase—which occurred even though crime rates declined—is that rural counties tend to have limited resources to build alternatives to jail for people who have mental health or substance use disorders. Another is that rural county jails confine a growing number of individuals for other authorities, such as state prison systems.10
People transitioning from incarceration face many challenges—particularly in housing, employment, and health care. In rural counties with struggling economies and limited resources for mental health, substance use, and other needs, these challenges can be even greater.11 Individuals with OUD in rural areas face a shortage of MOUD providers. Distance and transportation are common challenges. So is a lack of anonymity that can make it hard to seek treatment in a small community.12 People with a history of incarceration carry an additional burden of stigma beyond OUD-related bias, which can negatively impact their health care.13
Support through—and for—primary care
People with OUD who were recently released from incarceration need support in accessing treatment. Simultaneously, rural providers who serve them post-release need support in providing care for this population.
Implementing a Transitions Clinic Network (TCN) program in a primary care practice—preferably in a Federally Qualified Health Center (FQHC), which provides funding for behavioral health and navigation assistance—is a way to address the health risks and other challenges of reentry in rural communities. A TCN program provides recently released patients with care for chronic health conditions including OUD. It distributes naloxone and plays an important role in life-saving MOUD treatment. TCN programs can provide the spectrum of needed MOUD treatment—from induction, to maintenance, to referrals to higher levels of care—but specific TCN programs vary in where they land on this spectrum. For instance, some programs focus on prescribing maintenance MOUD after patients have completed the induction phase through an inpatient or outpatient treatment program, while other programs induce patients themselves and provide counseling for MOUD on site. Following this stabilization period after release from incarceration, patients remain in the TCN program or the broader primary care practice and continue to have MOUD prescribed in primary care.
Through culturally informed and trauma-informed care, a TCN program also seeks to reduce the stigma patients face. A community health worker (CHW) embedded in the practice, who has a history of incarceration, connects with individuals before release and coordinates their care. CHWs builds relationships with SUD treatment programs, transitional housing, and other resources to support warm handoffs upon release. They work closely with patients to navigate services in the community, including in the areas of employment, insurance, and parental rights. Adding a CHW to manage this work at the clinic can make the job of the primary care provider much easier.
For a practice interested in becoming a TCN program, comprehensive implementation assistance and ongoing support are available through the network. TCN works with clinics across the U.S. to adapt the TCN framework to the particular needs of the community. Studies have found that this model can reduce emergency department visits, preventable hospitalizations, and reincarceration for parole or probation technical violations.14 They support the autonomy and health literacy of patients and lead to successful receipt of primary care, SUD, and mental health treatment.15
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Part 3: Live Q&A
Live Q&A Recording
hi everyone i'm tedra cobb and i am so happy to have you here today for this important a webinar uh thank you for joining the ur medicine recovery center of excellence qna about the transitions clinic network programs this is a live session and it is part of a series of workshops webinars there are two recorded segments about this program if you have seen them that's great if you've not that's okay too because they are on our website uh and you'll be able to watch them at any time the webinar today is a product of the hersa rural communities opioid response program we are delighted to be one of the rural centers of excellence on substance abuse disorder and to have the opportunity to discuss this topic with you today so we often get the question what does your center of excellence do we've been working diligently since the fall of 2019 to reduce morbidity and mortality related to substance use disorder with a particular focus on synthetic opioids while our target service area includes 23 appalachian counties in kentucky ohio new york and west virginia that have been hit so hard by the opioid crisis anyone is welcome to benefit from our work to date all u.s
states and territories have participated in our events or used our products along with 48 other countries our approach is to disseminate best practices that we've identified through research and carefully adapted to rural communities today's practice around the transition clinics network program is one of these practices the focus or this program focuses on improving access to and engagement into care upon release from incarceration please reach out to us at any time for support in planning and implementing programs such as this one our contact information will be shared at the end of the webinar so without further ado what i would like to do is hand over to our two presenters today our experts dr morris and dr chaveed and i will let each of them introduce herself to you hello dr morse yes good afternoon i'm diane morris i'm a physician i'm an internal medicine physician here at the university of rochester and i am a clinician i see patients and i also do research and teaching and i have been directing a transitions clinic here in rochester since 2012.
shira good morning everyone i'm shira shavit i'm a family physician and faculty at the university of california in san francisco and i too see patients coming home from incarceration at a federally qualified health center in san francisco and i direct the transitions clinic network which is an organization that supports primary care clinics in caring for communities that are impacted by incarceration so i'm thrilled to be here today and um thank you to the house for having us thank you so much and thank you for being here and for being uh you know helping all of uh us and rural communities uh provide the services that are so important dr morse um has a few slides for us to um to learn about what they're doing and the programs and to give a little bit of a refresher so um dr morris you want to help us with that yes thank you so we're just going to refresh a little bit of what we covered in our uh prior webinars and again you're welcome to please listen to those watch them and and hear more details uh the transitions clinic network is a program and it that addresses um and focuses on access to an engagement into care for people who are coming out of incarceration we also address overdose and other health risks there are many health risks that are increased for people who are coming out of incarceration and difficulty accessing care we also help with access to medications specifically for opioid use disorder and there are many barriers in rural communities to getting this care that we address we utilize extensive community partnerships that provide services to and also are releasing people and overseeing them community supervision from incarceration so we have a lot of different kinds of partnerships that help us in our mission we have formerly incarcerated community health workers who really form a lot of the backbone of this program because their lived experience of incarceration and re-entry uh is crucial to this uh program and we have extensive uh support from the transitions clinic network that shera directs which helps provide support and education and direction to the work that we do wonderful thank you so much so we are going to spend the vast majority of today's time on your questions and uh really being able to dig into those questions and and have a conversation as much as we can about about your needs and your concerns but we'd like to start uh by having a quick poll and we're wondering which topics you think um are more pressing for you and you'd like to discuss and learn about so we're going to uh to do a poll you are able to respond to more than one so it's not just one you can respond to more than one and we're uh we'll give you a moment to do the poll and um steve i think is going to start that poll for us so okay okay i think the poll is done so steve can you show us the results of that fantastic thank you so much so it looks like it looks like we had a few things that percolated definitely that percolated to the top let's see here um access to care for formerly incarcerated individuals in rural communities that looks like that was very high up there and stigma around history of incarceration and or opioid use disorder those are the two that really came up to the top and i think the other one is community partnerships so fantastic i'm just going to give everyone one moment so you can sort of see where everybody is in terms of responding okay fantastic so what we're going to do now like i said is we'll spend the vast majority of the time in questions and answers so if you have a question please type your question in the q a box where we will see them uh those questions and then uh dr morris and dr chevy will be able to address those questions and we'll really try to move along i'm gonna say if we don't have time for all the questions it it's okay we will circle back um and we'll make sure that we address those questions um if we don't have time for those today so if we're ready for questions and maybe while you're typing in your questions here okay i'm going to put that there maybe while you're typing in your questions i can start out while you're thinking those and start out with dr morris and dr chaveed and maybe starting with that that concern about access to health care if you want to start by addressing that since that was the top on people's priority um dr morse or dr shavit do you want to start by addressing that while people type in their questions start with some comments about what people find here when people are released depending on where they're released from and what their program supports they may not they usually do not have an appointment for a primary care provider upon release and if they don't have that appointment they uh likely you know these are the things that we provide so if they don't have we provide make sure that they have an appointment we aim for that to be within the first two weeks after release we you know get notified of their release and we have a relationship with the um either jail or prison and send for their records so when they come in we have access to their medications to their vaccine records and if we don't have it that day because if we haven't made an appointment far enough in advance we know what their fax numbers are and what their protocols are for getting those records so we're really prepared because a lot of the time one of the biggest problems is if people do not have the medications that they have had while they're in jail or prison uh obviously that's a huge barrier to health and then they may end up in the emergency room or end up quite sick um dr chaveed you have anything to add to that uh thanks diane and i think what i'd like to add you know is just kind of taking a step back and thinking about that access issue you know i think one of the biggest challenges around access is insurance so as many of you know when people are incarcerated they if they have insurance or have medicaid they may lose that during their incarceration they may or may not be re-enrolled upon release and even in some states where they do a great job of re-enrolling people the insurance needs to be activated so there's many steps that people need to face kind of in getting that um you know access to getting services to begin with and then kind of as dr morris pointed out then there's kind of that connection to the clinic and so our work with with primary care clinics in the community is helping them build those relationships with the criminal legal system with community-based organizations so that they can connect with people early on to help them through that whole cascade around access you know helping them get enrolled for either medicaid or other types of coverage that they might be eligible for ensuring that they're able to link to the community health system um and kind of follow through on the steps and getting an appointment and then showing up for the clinic so even thinking about things like other barriers to access like transportation is another thing that clinics may focus on you know i was going to ask about that yeah i was going to ask about that because if somebody has an appointment how are you ensuring especially in rural places that don't have many of us do not have public transportation that they get to those appointments is there something so i think that it's tricky with the public transportation because one of the things that we do like business we'll get a letter from a prison saying that somebody's going to be released and can we mail back an appointment for them and we can do that and we can also when we know the person's address mail them or have one of our community health workers bring a bus pass or some kind of transportation assistance for them um if they have in where we are located um medicaid can also provide transportation so if somebody is uh registered is like we already heard if they're at if their health insurance is activated we consider um medi-cab is what we call it here to pick them up um prior to their appointment great yeah yeah that is a transportation is a huge barrier right in rural places right so we do have a question so uh the question is how can this program be adapted to address issues in the aaa lgbtq plus community particularly aaa among for gay men so i think that's a great question and i'm going to start off and then dr morris may have something she wants to add to that i think so this is a model of care that was developed in the community in san francisco thinking about how do we tailor our services to the needs of people who are returning from incarceration but the structure of the program is really meant to be adapted to each individual community and we've worked with 48 different communities in 14 states and puerto rico both urban and rural communities and really it's sort of a framework for how do you approach working with these patients but the specifics actually comes out in the work that we do with the clinics in their own communities so depending on the focus of the community the programs may look a little bit different and it's about building relational legal system but also with community-based organizations who are going to be a big part of providing services as well as referrals for these patients all of the programs have community health workers who have lived experience of incarceration but may also reflect the community that they're serving in other ways so for this particular case if you had a clinic that wanted to focus on um you know patients in african-american gay male community for instance having a community health worker who reflects that aspect as well as that history of incarceration is a great way to kind of engage that community working with community-based organizations that already specifically serve this population and then thinking about trainings for providers to ensure that the services in the clinic really meet the needs of that community and so you know whether it's that community or other communities you know the program itself is really a framework that can be flexed to meet the specific needs of the community that you're serving i would also add to that you know our community health workers are people who are active in the community already and so a lot of times you know i'll occasionally take a learn not just occasionally but i will i really like to go out to our community sites uh maybe the ywca for instance and one of the community health workers will be with me and then they'll be you know people who are living there women who are living there who will just get very excited to see the community health worker with me and say hi they know her because she's worked in the jails and prisons here for some years she's worked in the community for some years people know her and love her and i think part of you know our community health workers they may not have uh gone to college in fact none of the three people on my team have gone to college but they have been working in the community have all that practical experience and that makes them qualified for this position and a lot of times people know them or in the course of their job they may have gone into the jail or the prison and seen people so people will see them and that really i know stigma was an issue and that really helps decrease the stigma because they see a person who has their experience who has been hired specifically to this position and knows a lot of the things that can help them that really helps to decrease the stigma it helps provide that transition between us as medical providers and the patients maybe i was going to say maybe following up a little bit in terms of incarceration and stigma with related to incarceration and oud especially again in rural communities dr chavit were you gonna wanted to add anything yeah yeah i wanted to actually highlight a study that was done by some of our colleagues in canada which is really interesting because what they did is they actually called clinics in their community to say that this was somebody with a history of incarceration looking for a primary care appointment half that you know they did that some of the time and then they also called just saying it was somebody from the community looking for an appointment and those individuals who did not identify as having a history of incarceration were twice as likely to get appointments in clinics so i think that stigma that people experience around their history of incarceration is very real and this is in canada where we have universe where they i should say we they have universal coverage we do not in particular you know the access to care are some major issues and so i think that stigma also plays a really key role in people accessing care within clinics i also know that you know people may be concerned about their uh how they may be perceived by staff in the clinic living in a smaller community particularly maybe disclosing that they have that history of incarceration or a history of opiate use and may not want to seek services because they may not want community to see that aspect of their lives and so i think it's important to recognize that so some of the work that we do with clinics is thinking about how do you transform your practice to make it more welcoming for people to reduce some of those barriers to ensure that you know your front desk staff who's answering the phone isn't inadvertently discriminating against people because of that history because we want people to come in and get treatment and so the work that we do with sites is training them across the clinic all the staff of how do you support these patients understanding challenges people have i think approaching it from a place of understanding often helps people reduce some of the stigma and discrimination they may face and then thinking about what are systems that could be put in place that may ease some of this and the the number one thing is that community health worker right somebody that the patient can knows often and trust who's like them uh who they can confide in and feel safe sharing that information and then help letting them help them navigate those systems as well great and you've talked about that just the urgency really of getting someone in so quickly within that two-week period uh so we have another question who coordinates the transition of people from jail to the community and maybe you've spoken to that some but if either of you want to address that and help fill us in here we try to have multiple avenues for people to access care so we have flyers that have the community health workers email address phone number we have the phone number of our clinic and uh i mean as far as coordinating it if we know when we know people are coming out when we'll go into the jail or prison and when we know you know the community health workers will help set up an appointment and let the people know the people at the prison know people who are coordinating releases at the jail sometimes can also reach out to us and then if if people call if patients call or if community-based programs call i know that that was another real interest is the you know relationship with community members so there might be somebody in a transitional housing program um and they will call and help set up the appointment so it really it depends on the situation if someone has a support system a lot of times the support system will call the office and we as uh sure alluded to we have our staff trained so that if someone calls and says they want an appointment what our program is called the wish program if someone calls and says they want an appointment with the wish program they don't ask them any questions about why they might or might not qualify they just say you know we're making an appointment for them um so we try to make it as easy and and as non-judgmental as possible sure do you have anything to add to them no i think i would just say you know we work with sites in building those relationships with the jail um and that you know in every location that we work it looks a little different because of the barriers that you may face you know we have sites that use telemedicine for instance to in reach and meet with patients we have some sites that go in and do groups with patients right so it's a huge range of what you may be able to do in your own community but just to let everyone know we form this program in the absence of any real connection to our local jail and so we also know how to find patients when they come out and we know how to connect in the community so this work is doable if you have those connections or not you know i think ideally it's nice to start that earlier but we recognize that there's a lot um to changing those systems and really being able to work well with the criminal legal system so work is totally doable even if you don't have those and that's usually something we work with sites on building those relationships over time and it has been harder to get in covid because of the precautions that they need to take so that's an excellent point that we need to be able to do that with or without the ability to go in there yeah and what's interesting about that is it's harder to go in but then in some cases we found that it's easier to connect virtually because of everything being kind of closed down the jails and prisons are more open people have covet or have health needs coming out they're more aware of that so it's also been an opportunity to really forge those relationships i think also if your jail is providing moud or you know medications for opiate use disorder that's a real um hook to start those conversations of you're now putting people on these medications you know we can be a partner in ensuring that they get care in the community great i think i've heard the word partner many many many times so that's going to be our theme for today um we have another question uh to what extent were community members involved in relevant decisions during the formative stages of this program i love that question thank you so much i mean i think they were from day one they were involved in the development of the program in san francisco so we partnered with uh advocacy organization in our community with local community members who were impacted by incarceration with our community college and our department of public health and we were able to better understand what we were missing in our own clinic of what we weren't doing to meet the needs and so the entire program was based on feedback key informant interviews with the community one thing though that i want to be really clear about is that it didn't end there by hiring people from the community and having them as part of our teams there's constantly we're getting feedback about what is working not working for the community we also support our clinics in developing community advisory boards to continue to get input so i i love that question and then i would also say it shouldn't just be in the formative stages of the program but it should be the ongoing work because i can tell you as a physician you know i have lots of ideas when we first started we had found out from our local jail that if we wanted to put they had space across the street and if we wanted to put a clinic there we could and so we i thought oh how convenient people will leave jail they'll go across the street they'll get their medications you know from a provider perspective it seemed really logical but what we heard from the community was that nobody would go to that clinic when people get out of jail they're not going to go see the doctor they went home and they want to get as far away from the jail as possible so i think it's a great example of how sometimes good ideas may just not work and you really need that constant feedback from the community and that's really where the community health workers and then ongoing community advisory boards really plays into the success of the model at the sites that we work with great uh dr morris did you want to add anything well i would just say and i think this reflects uh this the question i saw flooding across is that the community also includes the clinic where we are housed and getting you know feedback from the nurses uh the you know front-facing staff who are answering the phone and coordinating everything is crucial and so we have evolved you know since we started this program here in 2012 with key you know input from the people who are on the ground with us and partnering with us here as well as partnering in in the larger community yeah and one of the questions is and you've spoken about stigma but um how have you um well what are some of the hesitancies that you have experienced and how did you manage them you've spoken to this a little bit but is there anything else you want to add in terms of hesitancy go ahead first yeah i'm sorry diane do you have anything you want no you can go first enough okay sorry yeah i mean i think um i'll just give you an example of some of the work we've done with sites in that training to address that hesitancy we usually do what we call a kickoff event where we actually go on site and do training with the entire staff like i mentioned from the front desk you know all the way through the providers who may be seeing patients so a lot of it is trying to demystify or d you know the myths that people may have and be have a forum where people can express their concerns and also hear from people who have done the work which i think is really helpful so you know i think there's a lot of beliefs around people with histories of incarceration in our society that um can be demystified i think people don't always have a framework for um you know mass incarceration why in our country so many people have been impacted by the laws and policies around incarceration like particularly people with substance use disorders so we'll we often will do this training that can you know range from a few hours to a full day event which we've done we did at our site in el paso texas but we do things like we have a values clarification exercise to help people understand where some of these ideas that they may have come from we do a a patient panel where patients can talk about their own experiences incarcerated and coming home to the community where we also have you know providers or community health workers talking about what it's like to do this work and it's a really open forum with opportunities for people to have these conversations you know and i think also recognizing this is an ongoing process over time but i think it's really helpful um to have these you know opportunities in training and reframing some of these ideas and sharing information that often helps demystify what people believe because it's not really grounded in fact i also think that a lot of time hesitancy can come from not feeling competent you know in terms of what you know about motivation um so we really try to help people feel really uh prepared to address the needs um so you know a lot of times uh if people are incarcerated and they're not used to for instance maybe injecting their own insulin if they're diabetic or managing their own medications um you know we talk to people about we talk to our staff of the needs and you know staff have gone into this field because they want to help people and helping them understand you know in what way they can be helpful um i think really increases their motivation and decreases their discomfort yeah can you speak to um there is a question about some of the basic needs that people have um so what basic needs that people have before um i think leaving in car as they leave incarceration what are the needs that that you're seeing and how are you addressing those you speak to that you just spoke to that a little bit but is there anything else you'd like to add there you know housing and food a child really uh specializes in taking care of women so particularly for women these issues are important sometimes they might have lost a child to child protective temporarily so them you know find legal assistance and really counsel them about um when would they be ready you know really help them think about when might they be ready to take their child back as opposed to trying to take them back too soon and then maybe having a relapse so people here you know who are very open-minded and understand what people are facing uh domestic violence is a huge people issue that that women are facing a lot of the women are used to sex work as a way to earn money and keep themselves going whether it's getting money or food or drugs so we are very honest and direct about that and help them access maybe pre-exposure prophylaxis uh medication for substance use disorder so they don't have to be getting it on the street uh so just you know because we anticipate and know what a lot of the problems are i think it decreases the stigma and also helps them uh feel confident that that we know what their problems are so those are some of the basic needs certainly uh housing shelter food all those things are really important thank you so much did you dr shavit do you want to ant you know i mean i think just to highlight the community health workers are really instrumental in guiding people and connecting with services in the community that may address these needs you know all the social determinants of health kind of everything is up in the air when people come out all at once so it's really overwhelming and sometimes it can be a barrier for people to access healthcare services because they're just trying to meet their basic needs and so i think another important piece is just some of our programs have done really innovative work and doing things like just putting a a small food bank within their clinic so that people could come for something to eat as a way to connect and get them engaged in care or providing some clothing or clothing vouchers for people who are seeking employment you know so they can buy work booths to go for a construction job or you know so thinking this is really where you know getting feedback from the community about the needs so we can address those as part of their health needs to then ensure that people are able to pivot and focus on health needs because they're not trying to meet their basic needs so i think it's a really core component to the work that we do this really dovetails with the partnership issue because we also partner with people who are helping people find employment um and housing so you know letting them know about our program and we can refer back and forth to each other yeah so one of the questions that we had was actually about staff in the jails and detention centers and how you have been able to engage or onboard them so you're talking about community partnerships but you know are there barriers within facilities and and finding a collaboration there yeah i mean there are barriers and i think it's important to recognize that it's a very different type of organization than a healthcare organization and the focus is really different it may be more focused on safety and security than on medical care and so i think it's important to understand you know who you're working with and what their focus is and within that framework find a common point of collaboration so i think some of the successes have been if jails do medications for opiate use disorder that connection right this idea that that helps them understand that you know we need to continue this medication covid has been a great way to leverage those relationships because people are leaving um with potentially a medical need right maybe they have a test that comes back positive um right before they go or or after they've left so there's definitely and also just i think a lot of our sites have made themselves very useful to the jail as being medical providers around covid so looking for ways to find a way to be helpful to connect when there is maybe less openness or understanding of how that role can be played i think also our work has shown that by patients who are getting care in our programs have a reduction in parole and probation violations and they spend 25 days fewer reincarcerated in the first year post release is a great way to frame the work and talking to our criminal legal partners so you know i think um and also increasingly probation and parole is um interested in you know supporting people in the community around these needs i think there's a growing awareness so i think you know trying to build those relationships and finding points of ways we could support and commonality um and then building off of those great thank you well we have we have time for one more question and this question is actually addressing stigma what is the biggest barrier uh regarding stigma in providing moud that you've encountered um and i think we might have addressed some of the staff and onboarding and um so what what maybe talking a little bit about the the stigma and maybe some of the biggest things that you hear or hurdles one of the big things that comes up is um actually gotten quite a bit better but it has to do with access to what i would say suboxone i call it suboxone buprenorphine um access to that has is still a challenge in many communities particularly rural communities so if you have somebody who is maybe still actively using and a primary care provider may say this is not for me um that can be a real now where i live it has gotten easier to have people access suboxone in the community and have treatment before they come here and then be in primary care after they're relatively stable but that's not true of everyone so i think having systems set up in the office to check maybe the whatever online system you need to check off and also knowing um using a harm reduction strategy and having the staff be open to that approach um i think is important sheriff what do you want to add to that yeah i think that i'm not sure what the biggest barrier is there's many and i think one also is you know the fact that people who are incarcerated may be seen as people who are not honest um and i think sometimes that really can play out in negative ways in treating people who have opiate use disorder and so i think it's really important that you're building uh good relationships with the patients that there's you know that trust piece is so critical in treating anyone with a substance use disorder so if people feel discriminated because of their history of incarceration feel like you're questioning what they're saying to you and not really believing them i think that's really going to harm your ability to have create a trusting relationship which is critical for addressing people's substance use disorder so i think that's a major issue that we see and that's why we have these programs is that we're drying off the community and thinking about how we change what we do so we can really build that trust and you know i think sometimes people see physicians and immediately there's some mistrust and often for good reasons people don't have good experiences during incarceration with providers or may have had negative experiences in the community before but having that community health worker who says you can trust this doctor she's cool like that really gets us so far in building these relationships and then um in the next step in trying to address people's substance use disorders and also co-occurring mental health conditions uh such as ptsd and depression can be a barrier as well it can interfere with people's trust and people's ability to function and stay organized uh you know to do the work that they need to do sometimes to stay on the medications right well thank you so much i um i'm sure that there will be more questions and i do want to remind everybody that if you have more questions uh reach out to us and um if we've missed a question we will circle back so we're recording this we'll look back at any questions but i think we did pretty well here addressing those questions um i want to make sure people know how to reach you so dr shavit will you tell us how to reach you and tcn yeah i just encourage if you have any more questions you want to reach out you're just even vaguely interested we'd love to have a conversation with you best is to reach our national program manager anna steiner as you see her email here or you can contact us through our website which is transitionsclinic.org
so please don't hesitate to reach out and i look forward to future conversations great and if you would like to reach out to ur medicine recovery center of excellence uh these are our contact uh numbers and uh we will we're there for you um and and both of both of the doctors here today are um will help you and be supportive so please don't hesitate to reach out again i want to say thank you for participating in today's question and answer if you will take a moment to answer the survey which is in the chat and will be available when you exit the platform today that would be great that'll help us in the future there will be a recording of this question that will be added to the website where you can also watch the first two segments and view the toolkit and finally you can get those if you visit recoverycenterofexcellence.org
and also lastly our program assistance is available to answer questions and to help with this and other practices thank you so much we are so honored that you took time to be with us today we wish you a safe and happy holidays and hopefully time uh in your communities with your family so again thank you so much be well and we look forward to staying in touch
Diane Morse, M.D., Associate Professor of Psychiatry and Medicine; Director of Women’s Initiative Supporting Health–Transitions Clinic (WISH-TC); University of Rochester Medical Center; UR Medicine Recovery Center of Excellence
Shira Shavit, M.D., Clinical Professor of Family and Community Medicine at the University of California in San Francisco; Executive Director, Transitions Clinic Network
Anna Steiner, M.P.H., M.S.W., Program Manager, Transitions Clinic Network
Evan Ashkin, M.D., Professor of Family Medicine, University of North Carolina School of Medicine; Founder of Formerly Incarcerated Transition (FIT) Program
 Substance Abuse and Mental Health Services Administration (SAMHSA). (2019). Use of medication-assisted treatment for opioid use disorder in criminal justice settings. National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration, p. 3.
 Binswanger, I.A., Stern, M.F., Deyo, R.A., Heagerty, P.J., Cheadle, A., Elmore, J.G., & Koepsell, T.D. (2007). Release from prison—a high risk of death for former inmates. New England Journal of Medicine, 356(2), 157-165.
 Green, T.C., Clarke, J., Brinkley-Rubinstein, L., Marshall, B.D.L., Alexander-Scott, N., Boss, R., & Rich, J.D. (2018). Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry, 75(4), 405-407; Marsden, J., Stillwell, G., Jones, H., Cooper, A., Eastwood, B., Farrell, M., Lowden, T., Maddalena, N., Metcalfe, C., Shaw, J., & Hickman, M. (2017). Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England. Addiction, 112(8), 1408-1418.
 Centers for Disease Control and Prevention (CDC). (2018). Evidence-based strategies for preventing opioid overdose: What’s working in the United States. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, p. 22. SAMHSA (2019) features the Kentucky Department of Corrections’ approach to providing MOUD and linking to services upon release, including referrals to Recovery Kentucky for ongoing treatment, p. 42.
 When MOUD is provided during incarceration, patients typically do not have access to any of the three FDA-approved medications (methadone, buprenorphine, and naltrexone). Blanco, C., Ali, M.M., Beswick, A., Drexler, K., Hoffman, C., Jones, C.M., Wiley, T.R.A., & Coukell, A. (2020). The American opioid epidemic in special populations: Five examples. NAM Perspectives. Discussion Paper, National Academy of Medicine, pp. 2-3.
 McFarling, U.L. (2021, February 16). As the pandemic ushered in isolation and financial hardship, overdose deaths reached new heights. Stat.
 Kang-Brown, J., Hinds, O., Schattner-Elmaleh, E., & Wallace-Lee, J. (2019, December). People in jail in 2019. Vera Institute of Justice.
 Kang-Brown, J., & Subramanian, R. (2017). Out of sight: The growth of jails in rural America. Vera Institute of Justice, pp. 16-21. See also Warren, D. (2020, January 21). Geography of incarceration shifts from urban to rural. Nonprofit Quarterly.
 Wodahl, E.J. (2006). The challenges of prisoner reentry from a rural perspective. Western Criminology Review, 7(2), 32-47.
 People who perceive stigma relating to their history of incarceration are more likely to report fair or poor health. Redmond, N., Aminawung, J.A., Morse, D.S., Zaller, N., Shavit, S., & Wang, E.A. (2020). Perceived discrimination based on criminal record in healthcare settings and self-reported health status among formerly incarcerated individuals. Journal of Urban Health, 97(1), 105-111.
 Wang, E.A., Hong, C.S., Shavit, S., Sanders, R., Kessell, E., & Kushel, M.B. (2012). Engaging individuals recently released from prison into primary care: a randomized trial. American Journal of Public Health, 102(9), e22-e29; Wang, E.A., Lin, H.J., Aminawung, J.A., Busch, S.H., Gallagher, C., Maurer, K., Puglisi, L., Shavit, S., & Frisman, L. (2019). Propensity-matched study of enhanced primary care on contact with the criminal justice system among individuals recently released from prison to New Haven. BMJ Open, 9(5), e028097; Shavit, S., Aminawung, J.A., Birnbaum, N., Greenberg, S., Berthold, T., Fishman, A., . . . Wang, E.A. (2017). Transitions clinic network: Challenges and lessons in primary care for people released from prison. Health Affairs, 36(6), 1006-1015.
Thomas, K., Wilson, J.L., Bedell, P., & Morse, D.S. (2019). “They didn't give up on me": A women's transitions clinic from the perspective of re-entering women. Addiction Science & Clinical Practice, 14(1); Morse, D.S., Wilson, J.L., McMahon, J.M., Dozier, A.M., Quiroz, A., & Cerulli, C. (2017). Does a primary health clinic for formerly incarcerated women increase linkage to care? Women's Health Issues, 27(4), 499-508.