Transitional Care Coordination Pilot Launched

A BPHC Innovation Fund pilot that provides transitional care coordination to people who are released from Rikers Island is up and running.

The Fortune Society launched its “Connections to Care” pilot in September 2018 and is engaging 100 clients in post-release health care and support services.

The pilot targets people who are chronically ill and at high risk of substance use relapse. Fortune staff work directly with clients while they are still on Rikers Island to create a customized plan that links them to medical care, substance use treatment, and community-based providers for other needed support services.

Care plans are personalized and can include an array of services like connection to a primary care provider, substance use treatment, specialists, and pharmacies; transportation to appointments;  and Medicaid enrollment. Fortune can help clients resolve insurance issues and identify organizations that can help with needs like housing, legal assistance, etc.

Clients selected for the pilot have been prescribed “opioid substitution therapy” (also known as medication-assisted treatment), such as methadone and buprenorphine, while incarcerated and are identified by NYC Health + Hospitals Correctional Health Services (CHS) as eligible to receive jail-based discharge planning and transitional care coordination upon release.

The pilot is modeled off the Drop-in Center, another successful Fortune program, funded by the NYC Department of Health and Mental Hygiene (DOHMH), aimed at people at Rikers Island and DOC jails throughout the five boroughs who are living with HIV/AIDS.

“Overdose is the most common cause of death post-release for people in the NYC jail system,” says Caitlin Shih, Manager of Program Operations and Analysis, Housing & Health Services at Fortune Society. “We took a model with which we are doing really well and are applying it to a group that is medically and socially vulnerable and has been shaken by the opioid epidemic.”

Fortune is well suited to this work as it is one of several organizations in New York City that are authorized to work with clients on Rikers Island. Between its long-standing Drop-in Center and I-CAN (Individualized Corrections Achievement Network) programs, Fortune has been working with individuals on Rikers Island for over 20 years.

“Fortune helps people successfully re-enter the community,” says Ronnald Harriotte, Transitional Specialist Coordinator. “Clients coming out of incarceration who have a history of addiction often need a specialized type of care coordination with focused health services and community-based support. If those needs are unaddressed, the person is at risk of continuing the cycle of relapse, deteriorating health, and the need for acute care.”

Harriotte notes that people who are newly released from the jail system often have misinformation about their options and processes for accessing care and services.  “This is especially true in our complex health care system,” he says. “Many people who leave the jail system lack health insurance or even an ID and are not empowered to advocate for themselves.”

Harriotte cites a client who learned he wasn’t eligible for a substance use treatment program because he missed the referral deadline by a day. “Fortune staff were able to reach out to the program and resolve this issue to help the client avoid a relapse and a possible visit to the hospital,” he says.

The pilot continues until July 2019. According to Harriotte, engagement has been positive.

“BPHC is excited to support pilot programs that bridge the gap between patients’ medical and social needs,” says Dr. J. Robin Moon, BPHC Senior Director of System Integration. “Programs like this speak to what we mean by ‘providing the right care at the right time and right place’ to benefit patients and the health care system.”

For more information, contact Shqipe Gjevukaj at