Abstract
Background
Previously incarcerated individuals experience a significant and vulnerable time post-release, highlighted by a greater than 129 times higher risk of overdose death. Many factors contribute to this high mortality including lack of health insurance and medications for opioid use disorder (MOUD) prescriptions upon release. Telemedicine provisions for MOUD greatly expanded access to MOUD for persons who previously could not engage in healthcare settings during critical times. Few rapid access, multidisciplinary transitional services exist to capture people in the immediate post-release period and address barriers to treatment engagement and retention. This quality improvement project describes the RIvER Clinic in Pittsburgh, PA which is a transitional post-incarceration clinic that provides multidisciplinary care services including a novel telebridge MOUD program immediately accessible for individuals post-release.
Methods
This quality improvement project was conducted using retrospective chart review during 3/1/2021 to 2/1/2025. Data from a year prior to engagement was additionally obtained. Patients who received a telemedicine bridge prescription of MOUD with the RIvER Clinic were included in this study. All patients had a previous history of incarceration.
Results
250 patients met the inclusion criteria. 91.6% of telebridge visits resulted in an MOUD prescription on the same day as the initial patient call. 73.6% of telebridge patients presented for a subsequent in-person clinic appointment. The average number of telebridge prescriptions prior to a completed in-person appointment was 1.18. There was a 40% reduction in emergency department (ED) utilization comparing the one year before vs the one year after a telebridge appointment. One patient had a fatal overdose.
Conclusions
The time period post release after incarceration represents a vulnerable time with exceedingly high risk of opioid overdose, death, and poor access to healthcare. The provision of MOUD via telemedicine offers a potentially lifesaving access point to limit overdoses post-release and provide an avenue for meaningful engagement. The RIvER Clinic model shows that offering telemedicine bridge prescriptions for MOUD prior to in person engagement can bridge an important gap and improve healthcare access. This innovative care model shows high in-person treatment engagement, a reduction in ED utilization, and a reduction in rates of overdose mortality.
Keywords: Telemedicine, Opioid use disorder, Medications for opioid use disorder, Incarceration
Background
Incarcerated individuals detained in jails and prisons are disproportionately affected by chronic health conditions including mental health issues and substance use disorders (SUDs) as compared with individuals who have never been incarcerated [1, 2]. Offering medications for opioid use disorder (MOUD) during incarceration can mitigate overdose risk upon release to a degree, but the effect is temporary [3, 4, 5, 6]. The benefits of MOUD within the carceral facility quickly deteriorate, particularly in situations where limited or no MOUD is given upon release, coupled with poor access to treatment post-release [7, 8]. Specifically, the immediate time following incarceration represents a vulnerable period of increased morbidity and mortality, especially for individuals who use substances, resulting in a more than 129x increased risk of overdose death and a 12x increased risk of all-cause mortality in the first two weeks after release [9]. The most common cause of death during this immediate post-incarceration period is opioid overdose. A review in 2010 reported that 76% of deaths in the first 2 weeks after release and 59% of deaths within the first 3 months of release were due to drug-related causes [10]. These data highlight the challenges that arise during the transition from incarceration to the community, a high-risk period for disengagement from the cascade of care. There are a myriad of factors related to the high mortality risk after release including loss of opioid tolerance while incarcerated and multiple stressors during re-entry [11, 12]. Additionally, the frequent barriers to entrance and retention into care post-release include structural factors such as loss of insurance, loss of access to prescription medications, transportation, delays in clinic appointments, housing, and fractured social networks all leading to high rates of return to substance use, mortality, poor retention in care, and high utilization of the emergency department (ED) [13, 14]. Particularly during the COVID-19 pandemic, there were efforts to rapidly reduce the population in detention settings, a process known as “decarceration” [15]. Decarceration disrupted the limited existing post-release processes such that individuals were released with fewer relationships with local services, without access to medications, and often while actively detoxing [16–18]. Little is known about the types of treatment and level of quality of care to which justice-involved people are referred. Only 4.6% of justice-referred people received MOUD in the community compared to nearly 41% of persons referred from other sources [19]. However, connection to OUD care can help reduce some of these detrimental outcomes. A cohort study in Australia showed that receiving MOUD in the 4 weeks post-release from incarceration reduced the hazard of death by 75% [5]. There is a paucity of data exploring the transitions between MOUD maintenance during incarceration and community-based treatment, and what factors influence treatment continuation and retention in care. Finding innovative solutions to bridge this gap is critical to improving long-term access to MOUD and reducing detrimental health effects after release [20].
Telemedicine has been an increasingly utilized entity to improve rapid access to MOUD [21]. Bridge clinics utilize telemedicine and are non-stigmatizing environments that offer harm reduction services, immediate access to MOUD, assessment of co-occurring physical services and social determinants of health with the ultimate goal of linkage to community resources [22]. Those connections to community resources can often be challenging for patients to access during the immediate post-incarceration time period. Multiple ‘handoffs’ to different organizations or clinics propagates the fractured healthcare landscape for this particularly vulnerable population. Creating a unified care model which provides in-jail assessment, immediate telemedicine access, and in-person clinical capabilities may aid in improving access to care and many of the detrimental outcomes for individuals with OUD after release from incarceration.
To address these issues, the Rethinking Incarceration and Empowering Recovery (RIvER) Clinic was established in 2021. The RIvER Clinic aims to help people reestablish independent lives following incarceration by providing immediate access to primary care services, substance use (SU) treatment, overdose prevention, financial support, mental health care, and social services. Differing from other post-incarceration clinics, RIvER is outreach-focused, utilizes a telebridge program, and collocates its service into community settings rather than working exclusively in a fixed clinic space. To our knowledge this is the first post-incarceration clinic utilizing a unified care model which includes telebridge services for rapid access MOUD for patients leaving incarceration.
The RIvER Clinic’s multidisciplinary, community-centered team engages patients during jail detention and after release. The clinic serves as a bridge between incarceration and the establishment of permanent health care and social services in the community. Individuals eligible for RIvER services include any recently incarcerated adults with any of the following: SUD, hepatitis C, any chronic health condition (s), and/or social determinant of health needs (eg, unstable housing). The RIvER team comprises a community-centered, full-time team of 2 primary care physicians, a nurse navigator, a social worker (SW), a community health worker (CHW), a patient care navigator, and a peer recovery specialist (PRS) (Fig. 1) [23]. The physicians provide medical care through in-person and telemedicine visits. The nurse navigator focuses on new patient assessments, triage, wound care, and care navigation. The SW performs social determinants of health assessments, goes into the jail to meet referrals, provides social-service support, and brief interventions/therapy. The CHW performs community outreach, accompaniment of patients, and in-jail assessments. The Patient Care Navigator performs in-office medical assistant duties as well as assists patients with navigating the healthcare system, including obtaining necessary medical testing and subspecialty follow up appointments. The PRS provides support for patients, navigation to substance-treatment related programs, and harm reduction education.
Fig. 1.
RIvER clinic Model
Description of the intervention (Telebridge program)
The majority of RIvER clinic referrals ( > 85%) come from the local jail, through assessment from jail staff or from direct contact with the RIvER CHW and SW who go inside the jail to meet with established or prospective patients. Ideally most patients are connected with the clinic prior to release, but in order to ensure that no eligible patients are missed, the clinic partners with local post-release programs who notify RIvER staff when they identify a patient who may be eligible for services. Patients are given business cards and brochures with the available services offered and the RIvER clinic contact information, which includes a cell phone number that connects directly to the nurse navigator. Patients call the RIvER cell phone which is answered by the nurse navigator Monday-Friday 8am-5pm, and if they are in need of a health assessment, the covering physician is added to the call in real-time to address physical health needs including withdrawal management and medication therapy. If MOUD is indicated and desired by the patient, MOUD is prescribed at the time of the initial telebridge call and the patient is subsequently scheduled for a follow-up in-person appointment. If patients are uninsured or their insurance is inactive, dedicated funds are used to pay for the prescription until insurance is activated. Once a patient is reached, whether in jail or in the community, the RIvER team performs medical, psychological, and social assessments of the person’s needs using validated questionnaires and screening tools. The RIvER team discusses each case to create an individualized, patient-centered, comprehensive care plan. In addition to medical care, the clinic helps patients find housing, employment, and legal supports, hoping to connect patients to community resources, and improve health and societal outcomes. The purpose of this article is to describe the implementation and preliminary outcomes of this novel telebridge program for recently incarcerated individuals with an OUD.
Methods
The study population included aged 18 or older released from incarceration with a diagnosis of OUD who were evaluated at least once by the RIvER Telebridge program for MOUD between 3/1/2021 to 2/1/2025. The majority of patients were released from the local county jail, while a small portion were released from surrounding county jails or state prisons. We performed a retrospective chart-review within the electronic health record for a single 10-hospital health system. Outcomes included time from patients’ first contact with the RIvER team until an MOUD was prescribed, as well as treatment retention after an initial telebridge visit, including time to and rate of completion of an in-person clinic visit. Additionally, we performed a pre-post study assessing ED utilization by patients within the one year prior to and the subsequent one year following an initial telebridge appointment. Fatal overdose rate was also assessed.
Given the unique nature of the bridge clinic model, a comparison group could not be developed, as an initial visit with a treatment provider would be an outcome of the bridge clinic and, therefore, would not be a comparable index event. Consent for participation was determined to be unnecessary given the nature of the study as determined by the Allegheny Health Network IRB which approved the project and publication as a quality improvement initiative. Clinical trial number not applicable.
Statistical analysis
Continuous variables are reported as mean and standard deviations, median and interquartile, and ranges, while categorical variables are presented as frequencies and percentages. We used Wilcoxon signed-rank test to compare the ED visit before and after bridge prescription. All statistical analyses were conducted under alpha level 0.05 via SAS 9.4.
Results
250 patients met the inclusion criteria. 77% were male, 84% were under age 50, 66% were white, and 69% had state Medicaid insurance while 23% were uninsured (Table 1). 91.6% of telebridge visits resulted in an OUD prescription on the same day as the initial patient call. 73.6% of telebridge patients presented for a subsequent in-person clinic appointment. The average number of telebridge prescriptions prior to a completed in-person appointment was 1.18. The average number of in-person clinic follow ups over the study period was 9. 58% had 5 or more clinic appointments within the following year after their initial telebridge prescription. There was a decrease in the average number of ED visits in the one year prior to the initial telebridge visit (0.25) compared to the average number of ED visits in the subsequent year (0.15), however, this change was not statistically significant (s = −179.5, p = 0.0648) (Table 2). Even though the Wilcoxon signed-rank test showed the difference of ED visit before and after bridge prescriptions was not statistically significant, the negative S value indicates that the number of ED visits decreased after the bridge prescription. 33 patients had a reduction in the number of ED visits in the year after their first telebridge visit compared to the year prior. MOUD prescriptions for 58 uninsured patients were paid for at the time of the initial telebridge visit. One person who completed a telebridge visit had a fatal opioid overdose (Table 2).
Table 1.
Characteristics of telebridge patients
| N = 250 | % |
|---|---|
| Gender | |
| Female | 23 |
| Male | 77 |
| Age | |
| 20–29 y | 13 |
| 30–39 y | 48 |
| 40–49 y | 23 |
| 50–59 y | 10 |
| ≥60 y | 6 |
| Race | |
| Black or African American | 31 |
| White | 66 |
| Other | 3 |
| Insurance type | |
| Medicaid | 69 |
| Medicare | 8 |
| Uninsured | 23 |
Table 2.
Outcomes of patients enrolled in the telebridge clinic
| Variable | Mean(std) Median(IQR) Range/Frequency(pct) N = 250 |
|---|---|
| Number of telebridge prescriptions before a completed in-person appointment | |
| Mean(std) | 1.18(0.48) |
| Median(IQR) | 1(1–1) |
| Range | 1–4 |
| Number of in-person outpatient appointments | |
| Mean(std) | 9(10.73) |
| Median(IQR) | 5(0–8) |
| Range | 0–40 |
| Time difference between first contact and first bridge prescription category | |
| Same day | 229(91.60%) |
| Within 1 day | 5(2.00%) |
| Within 3 days | 3(1.20%) |
| > 3 days | 13(5.20%) |
| ED visit prior to bridge prescription | |
| Mean(std) | 0.25(0.84) |
| Median(IQR) | 0(0–0) |
| Range | 0–9 |
| ED visit after bridge prescription | |
| Mean(std) | 0.15(0.52) |
| Median(IQR) | 0(0–0) |
| Range | 0–4 |
| Patient presented to clinic | |
| No | 66(27.4%) |
| Yes | 184(73.6%) |
| Narcan prescribed | |
| No | 2(0.8%) |
| Yes | 248(99.2%) |
| Opioid overdose fatality | |
| No | 249 (99.6%) |
| Yes | 1(0.4%) |
Note. Std stands for standard deviation, IQR stands for interquartile range, pct stands for percentage
Discussion
The data show that telemedicine facilitates rapid, same day access to life-saving MOUD treatment. A 73.6% in-person follow up rate and an average of 1.18 telebridge visits prior to the completion of an in-person clinic appointment show that patients respond to this intervention and it is not obviating the need for more comprehensive in-person medical assessments. While the 40% reduction in ED utilization after an initial telebridge clinic was not statistically significant, it represents an important trend to reduce costly, fragmented healthcare utilization. Notably there was a single fatal overdose in this cohort (0.4%), a rate lower than reported in other post-incarceration populations (up to 10.6%) [24]. The ability to pay for MOUD prescriptions is also critical given the relatively high rates of uninsured patients on release. Funding was obtained through the county Department of Health and Human Services to cover the cost of MOUD until a patient’s insurance could be reactivated. The majority of the work during the study period was undertaken during the COVID-19 pandemic, a time of significant disruption in medical continuity which may have lessened the potential impact of the intervention. The success of this model despite those challenges speaks to the importance of this type of intervention.
The RIvER Clinic was designed to address disparities in health care access, engagement, and outcomes for individuals who have been incarcerated. The innovative telebridge model serves as a safety net to close gaps in the continuum of care, utilizing the same multidisciplinary team across all potential touchpoints: meeting with persons during incarceration, providing outreach services in the community, facilitating access to the telebridge program, and providing in-person care services. This collaborative approach is one that has been suggested in the literature [25]. Creating low-barrier, outreach-focused, multidisciplinary care models such as the RIvER telebridge can address issues experienced in reentry and aid in the navigation of this challenging landscape. Additionally, ensuring MOUD treatment initiation or continuation after release from incarceration is critical to carceral-based MOUD programs maintaining their protective effects and to reduce the high risk of overdose and death after release.
Innovative care delivery models that improve upon traditional delays and obstacles to OUD care are needed to optimize patient access within a critical time period after release. Rapid access to medication therapy can increase the likelihood that patients will follow through with subsequent treatment, with one study showing that there is significant attrition when patients are forced to wait even 2 days to access MOUD [26]. The majority of organizations assisting individuals after incarceration focus on social services. The RIvER Clinic is the only dedicated entity with medical care as its primary service, while simultaneously assisting with social needs. To our knowledge this is the first post-incarceration clinic utilizing telebridge services for rapid access MOUD for patients leaving incarceration showing a reduction in ED utilization, overdose rate, and increased treatment retention.
Access to telemedicine services is critical given the temporal urgency to initiate or maintain MOUD treatment immediately after release. Importantly, during the COVID-19 pandemic, temporary Drug Enforcement Administration (DEA) rules suspending in-person evaluation requirements for the initiation of controlled substance treatments, including both audio and audiovisual buprenorphine prescribing, allowed for expansion of bridge clinic services [27]. Prior reviews of bridge clinics suggest further study was needed to understand how bridge clinics facilitate connections with ongoing care and improve outcomes including ED utilization [28]. To our knowledge, this is the first study of its kind evaluating a novel telebridge program focused on the immediate post-incarceration period showing improved retention in care and a reduction in ED utilization and fatal overdose.
Limitations
There are several limitations worth noting. Data presented here were retrospectively extracted from the EHR of a single site without comparators and were not collected as part of a prospective evaluation design, so there are limitations to the generalizability of the results. The data represents utilization from a single, 10-hospital health system and could miss utilization from alternative health institutions. The observed cohort is small and the sampling and unique nature of the program limited creation of an appropriately matched cohort, so we chose a pre/post evaluation that lessens causality inference but adds real world observations. The analysis may not account for all services provided to patients. Recidivism was unable to be calculated and could have affected the post-intervention results.
Conclusions
A telebridge program for individuals with OUD released from incarceration led to rapid access to MOUD, high treatment retention, a reduction in ED utilization and a reduction in overdose mortality. This is the first study of kind showing real-world results from an innovative care delivery model focused on the post-incarceration population.
Acknowledgements
Not applicable.
Abbreviations
- SUD
Substance use disorder
- OUD
Opioid use disorder
- MOUD
medications for opioid use disorder
- ED
Emergency Department
- DEA
Drug Enforcement Administration
- RIvER
Rethinking Incarceration and Empowering Recovery
- SU
Substance Use
- CHW
Community Health Worker
- SW
Social Worker
Author contributions
JG created the available dataset. YY performed the statistical analysis. DV and TR analyzed the data and were major contributors in writing the manuscript. All authors read and approved the final manuscript.
Funding
No external funding was utilized in this project.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
The study adhered to the Declaration of Helsinki. The Allegheny Health Network IRB approved the project and publication as a quality improvement initiative and consent to participate was waived by the AHN IRB.
Consent for publication
Human Ethics and Consent to Participate declarations: Not applicable. Consent not applicable as determined by the Allegheny Health Network IRB.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.