RIvER Clinic: Rethinking Incarceration and Empowering Recovery—An Innovative Postincarceration Care Delivery Model Implemented During the COVID-19 Pandemic

Abstract

The Rethinking Incarceration and Empowering Recovery (RIvER) Clinic was launched in June 2021 to address the health disparities experienced during and after incarceration. The RIvER Clinic’s multidisciplinary, community-centered team engages patients during jail detention and after release via telehealth, collocated in community locations, on a mobile van, and in clinic. The clinic serves as a bridge between incarceration and the establishment of permanent health care and social services in the community. In 2022, a total of 479 visits were completed. The clinic provided multidisciplinary substance use support to all eligible patients, paying for 104 medication for opioid use disorder (MOUD) prescriptions for uninsured patients. Twenty-five percent of patients were transitioned to community-based care, and less than 5% of patients were reincarcerated. Despite some limitations, results demonstrate that the RIvER Clinic is successfully reintegrating a marginalized population into its community. The purpose of this article is to describe the implementation and preliminary outcomes of this postincarceration clinic.

Individuals detained in jails and prisons are disproportionately affected by chronic health conditions, mental health issues, and substance use disorders (SUDs) as compared with individuals who have never been incarcerated.^1,2 The time following incarceration represents a period of increased morbidity and mortality, especially for individuals who use substances.³

The burden of negative health conditions is exacerbated by inadequate access to health care,1 including limited financial resources, medical distrust, competing social and health-related priorities (eg, housing), and managing social and logistical harms caused by having a record (eg, discrimination).^4–6

During the COVID-19 pandemic, there were efforts to rapidly reduce the population in detention settings, or “decarceration.”⁷ Decarceration disrupted established postrelease processes such that individuals were released with fewer relationships with local services, without access to medications, and often while actively detoxing.^8–10

Postrelease care models, such as the Transitions Clinic Network, have improved health outcomes for individuals postrelease (eg, reducing emergency department visits, hospital stays, reincarceration).^11,12 Inspired by these models and the urgency resulting from the COVID-19 pandemic, Center for Inclusion Health in the Allegheny County Health Network (AHN) in Pittsburgh, PA. developed and launched the Rethinking Incarceration and Empowering Recovery (RIvER) Clinic in June 2021. The RIvER Clinic aims to help people reestablish independent lives following jail detention 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 postincarceration clinics, RIvER is outreach-focused and the team colocates its service into community settings (eg, social services) rather than working exclusively in a fixed clinic space. This Practice Brief Report describes the implementation and preliminary outcomes of this postincarceration clinic.

Program Description

The goal of the RIvER Clinic is to bridge incarceration to sustainable health care by first stabilizing patients’ medical and social needs and then assisting them in accessing sustainable health care and social services in their community. Individuals eligible for RIvER services include adults recently incarcerated in the Allegheny County Jail (ACJ) with a SUD, hepatitis C, 2 or more chronic health conditions, and/or social determinant of health needs (eg, unstable housing). RIvER comprises a community-centered, full-time team of 2 primary care physicians, a nurse practitioner, a psychiatrist, a nurse navigator, a social worker, a community health worker, a patient care navigator, and a peer recovery specialist (see Supplemental Digital Content Figure 1, available at http://links.lww.com/JPHMP/B302). RIvER uses a nonstigmatizing (eg, person-first language), harmreduction (eg, safe smoking supplies, wound care kits),¹³ trauma-informed care approach, focusing on patient needs rather than clinical requirements.

RIvER was established via grant funding and ensures long-term sustainability by obtaining and billing insurance and utilizing bundled payments for SU treatment through Medicaid payers. Local funding and contingency funds support extra expenses (eg, bus passes).

Most RIvER referrals come from ACJ (>85%); others are received from recovery houses, other departments in the Center for Inclusion Health, and community partners such as local Federally Qualified Health Centers and mental health providers. In addition, ACJ staff from multiple departments identify individuals who meet RIvER referral criteria at intake (≤48 hours of entry) and during discharge planning. A list of patients is e-mailed to RIvER staff 3 times per week and is revised daily to remove released individuals. During their 2 days per week in ACJ, the community health worker and the social worker provide health education and tailored support, introduce community-based services, and begin relationship building with the referred patients. If a patient is not identified prior to release, he or she can meet clinic staff outside of ACJ at a mobile van staffed 2.5 days per week (days RIvER staff are not inside the ACJ). If an individual is released outside of these times, the ACJ staff send a referral to the clinic staff who attempt to reach the patient in 24 hours or more. To ensure that no eligible patients are missed, the clinic partners with local postrelease programs and other AHN providers who notify RIvER staff when they identify a patient who may be eligible for services.

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 (eg, PTSD screening, Patient Health Questionnaire-9). 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 get them connected in the community and divert them from additional jail time. The physicians see patients via telemedicine throughout the week, during scheduled collocated outreach in various neighborhood sites (eg, soup kitchens, shelters), on the mobile van unit, and in a shared clinic space (1 day per week). In addition, psychiatric services are integrated into the clinic (1 half day per week). When needed, medications for opioid use disorder (MOUD) are ordered and a follow-up visit is scheduled. Because of a COVID-19–related policy that allowed practitioners to treat patients with OUD via telemedicine without in-person examinations,¹⁴ clinic providers can prescribe MOUD virtually, reducing a prepandemic barrier to access.¹⁵ If patients are uninsured or their insurance is inactive, dedicated funds are used to pay for the prescription while insurance is activated (with clinic staff support).

During the height of the pandemic, RIvER provided COVID-19–specific services including testing, distribution of personal protective equipment (eg, masks), and referrals to treatment and vaccine services. These services helped patients gain access to public transportation, shelter-based housing, and social supports that mandated mask usage or a negative COVID-19 test.¹⁴

To transition patients to community care, the RIvER team works with health care and social service providers to schedule long-term care appointments. RIvER staff follow-up with patients and providers to ensure they are connected.

Preliminary Outcomes

We extracted relevant data from RIvER patients’ electronic health records (EHRs) (Table). Because of a new data management system being introduced to AHN during the clinic’s implementation, the reporting period described later varies on the basis metric reviewed. From June 2021 to December 2022, RIvER provided services to 602 patients at ACJ and 550 patients were referred for postrelease services. RIvER staff successfully contacted 60% of all referrals via phone or in person. The most common barrier to contact was a disconnected phone or no accessible voicemail.

TABLE.

Select characteristics of RIvER clinic patients, June 2021 to December 2022

	N (%)
June 2021-December 2022
Received referral for post-release RIvER services	550 (100)
Contact Attempted	550 (100)
Successfully Contacted	330 (60)
January 2022-December 2022 *
Completed RIvER office visits	479
# of unique patients completing at least one in-person visit	98
Visit Modality
In-Person	373 (78)
Phone	95 (20)
Video	7 (1)
Nurse	4 (1)
Gender
Female	21 (21)
Male	77 (79)
Age
20-29 years	13 (13)
30-39 years	46 (47)
40-49 years	23 (23)
50-59 years	10 (10)
≥ 60 years	6 (6)
Race
Black or African American	29 (30)
White	66 (67)
Other	3 (3)
Substance Use
Diagnosed Substance Use Disorder	90 (92)
Diagnosed Opioid Use Disorder (OUD)	82 (84)
Medication Assistance Treatment for patients with OUD (n=82)
Received an MOUD prescription	74 (90)
Buprenorphine	74 (90)
Narcan offer	82 (100)
Insurance Type (N=59)
Medicaid	53 (90)
Medicare	4 (7)
Uninsured	2 (3)

^*Note: Availability of outcome metrics changed in a database transition in January 2022, leading to differences in reporting periods.

In 2022, RIvER completed 479 postrelease visits with 98 unique patients. Most visits occurred in person (78%). Regardless of visit type (eg, in clinic or virtual), the appointment show rate was 60%. Of the 98 patients seen, the majority identified as male (77%), 67% as White, and 47% were between 30 and 39 years old. Ninety-two percent of patients had a diagnosed SUD; of those, the majority (84%) had an OUD diagnosis.

All patients with OUD were offered intranasal naloxone and multidisciplinary SU support. The clinic paid for 104 MOUD prescriptions for uninsured patients. Within 1 month of clinic involvement, 90% of patients were insured via Medicaid. Ninety percent of patients on MOUD were prescribed a buprenorphine product. Two patients (2.4% of those with OUD) died of overdose.

RIvER has successfully transitioned 25% of its patients to community-based care using a staff-supported referral and linkage process, and less than 5% of RIvER patients have been reincarcerated.

Discussion

The RIvER Clinic was designed to address disparities in health care access, engagement, and outcomes for individuals who have been incarcerated. Notably, a low proportion of RIvER patients (∼2%) experienced a fatal overdose, a rate significantly lower than reported in other postincarceration populations as detailed by Merrall et al¹⁶ in their meta-analysis of drug-related deaths following release. We also found a low rate of reincarceration (5%), which is less than other empirical evidence (eg, 14.9%−23%)¹¹; however, it is challenging to compare with other studies that examined reincarceration in more nuanced ways (eg, days incarcerated, type of arrest [eg, new conviction]).¹¹ This descriptive analysis supports emerging evidence that tailored care strategies for individuals leaving detention settings are needed to address barriers to care engagement.

There are several limitations worth noting. Data presented here were retroactively 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. In addition, a new data management system was introduced during the implementation of RIvER. Consequently, data were extracted from 2 systems contributing to challenges in metric consistency and identifying one continuous reporting period. To better understand the impact on reincarceration, future work should include more robust measures of reincarceration and qualitatively explore the pathways through which care engagement shape reincarceration. Finally, this descriptive analysis utilized quantitative data alone and therefore we are limited in describing RIvER from the patients’ perspectives. Qualitative evaluation work is being implemented to inform further service offerings. Despite these limitations, we were able to extract useful data to describe the preliminary impact of RIvER.

Our results show that RIvER is reintegrating a marginalized population into the community by stabilizing its medical needs and connecting it with social supports. Creating low-barrier, outreach-focused, multidisciplinary care models such as RIvER can address issues experienced in reentry and aid in the navigation of this challenging landscape. The RIvER Clinic is an example of such a model working well in, and for, its community.

Supplementary Material

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com).

Implications for Policy & Practice.

• Innovative health care delivery and service models are needed to address significant disparities in health outcomes and care access for those recently released from jail.

• Creating low-barrier, outreach-focused, multidisciplinary care models such as RIvER can address many of the issues experienced in reentry and aid in the navigation of this landscape for many vulnerable people.

• Caring for individuals released from incarceration, including via providing rapid-access health care, prescription funding, and linkage to social services, can support individuals who use substances get engaged in care and reduce risk of drug overdose and can increase accessibility to services.