CHW Workforce Development, Inc. Monthly Grand Rounds

Reentry, Recovery, and Continuity of Care: Supporting Patients Transitioning from Incarceration on MOUD

Hosted by: Rev Dr. Ali ABY Muhammed, CCHW

Format: Monthly CHW Grand Rounds Audience: Community Health Workers, peer recovery specialists, OTP staff, reentry programs, case managers, behavioral health providers, correctional health partners, and community-based organizations.

Program Description

CHW Workforce Development, Inc. is launching this Monthly Grand Rounds session to strengthen community-based care coordination for individuals entering or leaving incarceration while receiving Medication for Opioid Use Disorder, also known as MOUD.

Patients transitioning between correctional settings and the community face a high-risk period where gaps in medication, communication, transportation, documentation, or referral follow-up can increase the risk of destabilization and overdose. Current guidance emphasizes that communication between correctional OTP providers and community OTP providers is essential to maintaining continuity of care.

This Grand Rounds session will focus on the role of CHWs in reentry support, harm reduction, last-dose verification awareness, referral navigation, appointment follow-up, and patient-centered recovery planning.

Learning Objectives

By the end of this session, participants will be able to:

1. Describe why MOUD continuity is critical during incarceration and reentry.

2. Identify key communication needs between correctional OTPs and community OTPs.

3. Explain how CHWs can support patients before and after release.

4. Recognize common reentry barriers, including unstable release dates, legal status changes, transportation, stigma, and lack of documentation.

5. Apply a harm reduction and trauma-informed approach to reentry care coordination.

Featured Discussion Topics

1. Why reentry is a high-risk moment

Patients leaving incarceration may experience sudden release, court-based release, bail changes, or transportation barriers. These challenges can interfere with medication continuity and follow-up care.

2. The importance of last-dose communication

Correctional OTP providers are encouraged to verify medication dosing, communicate with community OTPs, and provide last-dose information whenever possible.

3. Keeping the community treatment connection active

Community OTP providers may consider a patient’s legal status and sentence length when deciding whether to keep a case open or discharge the patient from treatment.

4. CHW role in reentry care coordination

CHWs can help patients understand where to go after release, reconnect with treatment, schedule appointments, address transportation needs, support communication with providers, and reduce fear during the reentry process.

5. Using communication forms and referral pathways

The guidance includes a Community and Corrections OTP Communication Form to support information sharing around facility type, legal status, release planning, and community OTP patient status.

Suggested Monthly Grand Rounds Agenda

Opening Welcome — 5 minutes

Introduction from CHW Workforce Development, Inc.

Case Presentation — 15 minutes

A patient is released unexpectedly from a House of Correction and arrives at a community program without a last-dose letter.

Guided Discussion — 20 minutes

What should the CHW do first? Who needs to be contacted?

What information is needed to prevent medication disruption?

How can the team reduce overdose risk?

Practice Tool Review — 10 minutes

Review of care coordination steps, OTP communication points, and reentry referral workflow.

CHW Reflection — 10 minutes

How do we support dignity, recovery, and trust during reentry?

Closing and Next Steps — 5 minutes

Monthly action item and partner follow-up.

Join CHW Workforce Development, Inc. for our Monthly CHW Grand Rounds: Reentry, Recovery, and Continuity of Care.

This session will explore how CHWs and community partners can support individuals transitioning from incarceration while receiving MOUD. We will discuss care coordination, OTP communication, last-dose verification, harm reduction, and the critical role of CHWs in preventing treatment disruption and overdose risk.

Continuity of care saves lives. Reentry support is harm reduction.

Call to Action

CHW Workforce Development, Inc. invites healthcare providers, OTP programs, correctional health partners, reentry organizations, and CHWs to join this monthly learning space. Together, we can build stronger referral pathways, improve communication, and protect recovery for people returning home.