Team-based, Low-barrier Care Improves Outcomes for Individuals Leaving Incarceration

Posted on May 8, 2024 by Thomas Robertson, MD, FACP Leave a comment

This entry is part 14 of 15 in the series May 2024

A multidisciplinary clinic focused on low-barrier, immediate access to health care and social services for individuals following release from incarceration led to improved outcomes for patients.

The revolving door of American jails is a true public health crisis. Incarceration has many detrimental effects on people, including significantly worse health outcomes and decreased social connection. Individuals leaving jail face issues such as increased mortality within the first two weeks following release, significantly increased risk of drug overdose, higher healthcare utilization and cost, as well as reduced/disrupted access to social service programs such as welfare, food stamps, and housing services. Additionally, due to health insurance deactivation during incarceration, many patients are released with no access to medications or healthcare until insurance can be reactivated, which often takes weeks to months. These challenges disproportionately affect people from multiple marginalized backgrounds, and these disparities were exacerbated during the COVID-19 pandemic. While attempting to reduce jail populations, disjointed jail release processes worsened the availability and opportunities for coordination of medical care, behavioral health services, and social services during the reentry process into the community. To help address this crisis, we established the Rethinking Incarceration and Empowering Recovery (RIvER) Clinic, outlined in our JPHMP article “RIvER Clinic: Rethinking Incarceration and Empowering Recovery—An Innovative Post Incarceration Care Delivery Model Implemented During the COVID-19 Pandemic.”

The RIvER clinic is a multidisciplinary, outreach-focused healthcare team with the goal of helping people get back on their feet after release from jail. The team is comprised of two internal medicine physicians, a part-time psychiatrist, a nurse navigator, two community health workers, a social worker, and a peer recovery specialist. The team works together to help people reestablish independent lives after incarceration by focusing on addressing physical and mental health concerns, substance use treatment, and social service needs through a low-barrier, harm-reduction approach. The clinic was established in 2021 at the height of the COVID-19 pandemic via grant funding and has since become financially sustainable via health insurance billing and bundled payments.

A key part of the RIvER model has been developing strong working relationships with the county jail and various community agencies with the goal of integrating services for patients. Our partnership with the jail helps create a direct referral pathway for patients from the jail to the RIvER clinic. Additionally, it allows one of our community health workers and the social worker to go into the jail 4 days per week to meet with patients, collect information on medical and social needs, and provide support prior to release. Once a person is released from jail, they can directly contact the RIvER clinic to arrange an immediate telemedicine assessment by one of the physicians. At this time, medication bridge prescriptions can be ordered in advance of a subsequent in-person medical appointment. One of the unique components of the RIvER model is the facilitation of access to medications for opioid use disorder, regardless of insurance status, immediately at the time of release. Philanthropic funding pays for these prescriptions until insurance can be reactivated. Additionally, the team provides direct aid in assisting with social service navigation for things like health insurance, food, housing, employment, IDs, and transportation.

During its first 18 months, the RIvER clinic saw over 600 patients in jail and received referrals for 550 people upon release. We documented over 450 post-release visits, and over 90% of patients had a diagnosed substance use disorder. The clinic had high retention for patients, in part due to the provision of transportation access via bus tickets or pre-paid ride-share rides to clinic appointments. We were able to fund over 100 prescriptions for MOUD for uninsured patients, and 90% of those patients were able to reactive their health insurance within one month of engagement with the RIvER clinic. Importantly, only two patients died of an opioid overdose and less than 5% of RIvER patients were reincarcerated during this timeframe; both of these outcomes are lower than the high rates seen nationally in this population.

Given the high-risk nature of the reentry process, and the detrimental effects on health outcomes and social integration, a person-centered, multidisciplinary reentry team like the RIvER clinic is key to addressing these issues. While initial financial investment is needed to create a clinic like RIvER, and structural barriers exist, the downstream positive effects on critical outcomes are undeniable and invaluable. Our JPHMP article “RIvER Clinic: Rethinking Incarceration and Empowering Recovery—An Innovative Post Incarceration Care Delivery Model Implemented During the COVID-19 Pandemic” provides a framework for the creation and expansion of similar clinics throughout the country.

Acknowledgements

We are grateful for the amazing team especially co-founder and co-director of the RIvER clinic Dr Divya Venkat. And sincere thanks to Emily Dauria, Joslyn Lapinski, Mary Hawk and James Egan who provided invaluable support throughout this writing process.

Author Profile

Thomas Robertson, MD, FACP: Thomas Robertson, MD, FACP, is an internal medicine physician and co-director and co-founder of the RIvER Post-Incarceration Clinic. He is an expert in bedside ultrasound imaging and has clinical interests in medical education, health care for marginalized populations, and global health. Dr. Robertson received a medical degree from University of Maryland School of Medicine in Baltimore, Maryland. He completed a residency in Internal Medicine Global Health and Underserved Populations at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania.