HMA and the California (CA) Department of Health Care Services (CDHCS) are collaborating to expand access to at least two forms of MAT in CA county jails and drug courts in a statewide learning collaborative with technical assistance (TA) and provider coaching. Multidisciplinary teams from 34 counties are participating in the learning collaborative and demonstrating success in rapidly increasing access to MAT in jails and drug courts.
Intro and challenge
The California Jail MAT Expansion Project elevates jails as a key part of the safety net for addictions treatment by bringing together teams in each county that include stakeholders in county justice and substance use disorder system of care, centered on the jail and with each County sheriff as the lead sponsor. Teams have access to shared learning activities and ongoing individualized technical assistance and coaching from HMA subject matter experts (SMEs).
The project launched in May of 2018 when teams were invited and the first 22 teams were convened in August of 2018 in person in this large, statewide initiative designed to dramatically change the treatment landscape in jails and drug courts.
In undertaking this transformation HMA coaches and SMEs must understand and respond to the unique regulatory oversight, policies, and procedures in jail operations requiring customized approaches to introduce and expand MAT inside the jail. Both adaptive and technical change strategies are deployed to assist jails in changing their culture and operations to treat substance use disorder (SUD) like other chronic, treatable diseases. HMA coaches and SMEs stay deeply involved with county teams to initiate and support change over time.
There are now 34 participating teams and the data reported from 22 teams as of June 2021 confirms they had provided MAT to almost 15,000 individuals while in custody. When the project began in September 2018 less than 25 people were receiving MAT while incarcerated in the 22 initial participating counties.
Strategy/Approach/Interventions
Teams are required to submit an application to participate in the learning collaborative that includes information about the current state of MAT in their jail and drug court. This information is supplemented by calls with their assigned HMA coach to further understand their current operations, resource capacity, and goals. All county teams are convened for a collaborative learning session to “jump start” their implementation plan. This session includes fundamental information on MAT and related components of evidence-based substance use disorder treatment in jails and justice settings. On an ongoing basis each team is assisted by their coach to establish and execute goals and action steps
that align with the overarching goals of the learning collaborative. Coaches identify challenges and barriers at their sites and these themes inform ongoing webinar trainings and sessions at additional learning collaborative convenings. Bringing together a cohort of county teams provides an opportunity to understand at a broad scale the state of MAT in California jails and design targeted interventions to accelerate their implementation of MAT. Broad themes, such as biases against MAT among providers and custody staff; custody concerns about diversion of medications; and payment mechanisms for the medications and sufficient staff capacity to offer the treatment arise across the cohort and are subsequently targeted with training and hands-on coaching support. This ongoing collection of information from counties and close contact with teams and the HMA Team’s clinical expertise inform the unique approaches at each location.
Critical elements of the change effort include:
- Improved SUD screening, assessment, treatment options and planning to include at least two forms of MAT are core themes and goals of the learning collaborative. This messaging and expectation accelerate implementation by “setting a bar” for teams’ efforts while providing them with individualized assistance to overcome challenges in meeting their goals.
- Engagement across the treatment ecosystem in the county including advisors from state associations of counties, sheriff departments, treatment providers, and the state prison system connects the counties with emerging policy and best practice from their professional peers.
- Multidisciplinary teams: MAT in jails and drug courts requires an integrated approach inclusive of medical and behavioral health care staff, custody/security and other justice professionals, and county providers and leadership
This implementation model drives rapid, systemic change that would likely not be possible with individual county efforts. Scaling is accelerated by the learning collaborative model in which barriers that are identified by multiple county teams, such as regulations for methadone in the jail, or practice of a healthcare vendor serving multiple sites, are addressed at the levels of state policy or corporate leadership and addressed in group learning opportunities.
Lessons Learned
- The approach has to be tailored for each jail. Each jail and county have resources, concerns, and goals unique to them and the technical assistance must incorporate this understanding and meet them where they are to be effective.
- The aim – improved SUD treatment systemwide – including transitions when individuals enter the corrections system and again at release – needs to be addressed as a countywide problem that needs a countywide solution.
- Implementation of MAT in jails should be sponsored by the Sheriff and key partners from probation, jail custody, jail healthcare, drug courts, local county drug treatment programs, and the county administrator’s office must be included in planning and implementation.
- Do not underestimate the prevalence and impact of stigma. There is an ongoing need for broader education about addictions treatment including Probation and parole, judges and district attorneys, the community, children’s and family services, and even community providers and the self-help support community need to understand MAT as treatment, and more specifically, not as ongoing substance use that is construed as problematic.
- Do not go too fast: it is important to build supportable, sustainable implementation If teams are not given sufficient support and opportunity to evolve in their understanding and development of the implementation program they may fail. At the same time a sense of urgency is important because people are dying due to lack of access to needed treatment.
Key Successes/Outcomes
- As of June 2021, almost 15,000 individuals in jail in California have received MAT during their period of incarceration. About one third of those were initiated on MAT while in jail and others that had been receiving MAT in the community were continued on their customary dose when incarcerated. At the inception of the learning collaborative initiative in September 2018 the initial 22 participating county jail teams reported a total of less than 25 people who were receiving MAT while incarcerated. After one year of participation in the learning collaborative counties reported that 1,646 detainees had received MAT in custody, and 678 were in-custody initiation of treatment with buprenorphine. This represents rapid implementation and scaling driven by the learning collaborative model.
- All participating jails now provide naloxone to individuals with opioid use disorder (OUD) on release, a critical element to protect the safety of those individuals post release.
- The program was so successful the state awarded additional funding to maintain the 1st cohort and fund additional teams in 2020 and 2021. There are currently 34 counties participating that collectively represent 86% of the population of The project model has been replicated in 16 counties in 15 states in a national initiative with Arnold Ventures and the Bureau of Justice Administration; and in the states of Pennsylvania and Illinois.
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