The First Month Home: A Health Care Checklist for Reentry Staff

The first weeks after release are crowded: housing, work, transportation, check-ins with a parole officer. Health care slips easily, and for people with an opioid use disorder those weeks carry real danger. Here is a checklist reentry staff can work through with a client, drawn from the National Institute on Drug Abuse (NIDA) and the South Carolina Department of Health and Human Services (SCDHHS), and how to connect the client to Hope Health Network.

Why the first weeks matter

NIDA says people with an opioid use disorder face a higher risk of overdose after release. Time without use can lower tolerance, and many people go back to using at amounts close to what they used before incarceration, which the body can no longer handle. NIDA adds that treatment started during incarceration should continue after release through treatment in the community.

NIDA's research report on medications for opioid use disorder says people treated with medication while in jail or prison are less likely to overdose or to be arrested or incarcerated again after release, and are more likely to stay in treatment.

The checklist

• Coverage. SCDHHS takes Healthy Connections Medicaid applications online at apply.scdhhs.gov, in person at a county office, by phone at (888) 549-0820, or by mail. SCDHHS says a person who is not sure they qualify can still apply, either for Healthy Connections Medicaid or through Healthcare.gov.
• Treatment that continues. Hope Addiction Medicine provides medication-assisted treatment for opioid and alcohol use disorders. Treatment typically begins with an in-person assessment, followed by weekly in-person or virtual visits before moving to a monthly schedule, and each plan is tailored to the patient.
• A primary care provider. Hope Medical Associates provides primary care, including care for diabetes, hypertension and COPD, the Medicare yearly wellness visit, and help establishing a primary care provider after a hospital stay.
• Mental health care. Hope Behavioral Medicine provides psychiatric medication management and counseling for adults with anxiety, depression, ADHD, insomnia, PTSD, OCD, bipolar disorder and postpartum depression, in person in West Ashley and by video.
• Crisis numbers saved in the phone. Call or text 988 for a suicidal or mental health crisis, and call 911 for an emergency.

Updates for a parole officer

When treatment is a condition of parole or other release, 42 CFR 2.35 allows information to go to the parole officer and other criminal justice staff who need it to monitor progress, with the client's written consent that meets the federal rule. The people who receive it may use it only for official duties tied to the release.

How to refer

You do not need to choose a practice; we route each referral to the right one. The referral line, fax number and secure form are on our referral page, and reentry staff can read more on our reentry page. We typically contact the patient within two business days of a faxed referral, and initial evaluations are often able to be scheduled within a week of the request. If the patient needs to be seen sooner, call us.

Our practices accept Medicare, most major commercial plans, and all South Carolina Medicaid managed care plans except Select Health (First Choice). Self-pay rates are also available.

Our practices are not an emergency service, and the referral form is not monitored for emergencies. For someone in crisis, call or text 988, and in immediate danger, call 911.

This article explains these rules in general terms. It is not legal advice.

Sources: NIDA, Criminal Justice DrugFacts; NIDA, Medications for Opioid Use Disorder research report; SCDHHS, Getting Started; 42 CFR 2.35, disclosures to elements of the criminal justice system.

This article is general information, not medical advice, and does not create a patient–provider relationship. Every situation is different, so see a provider who can evaluate yours and develop a plan of care. Any medication discussed here may not be right for you: the right choice depends on your diagnoses, other health conditions and current medicines, so take medication only as directed by the provider managing your care. If you are ever in doubt about an emergency, call 911 or go to the nearest emergency room.