Dedicated Prison Social Workers From Screening to Reentry
A Statewide Case Management Model Bridging Incarceration and Community Reentry for People with Substance Use Disorder
The Virginia Department of Corrections funds a statewide team of dedicated SUD Social Workers placed in 12 prisons across the state. Each social worker provides substance use disorder case management support at their assigned facility. This includes screening, group and individual counseling, medication for opioid use disorder navigation, and a substance-use-specific continuation of care plan that hands the person off to a community treatment provider and a probation district mental health clinician before release.
The Challenge They Were Addressing
Before the SUD Social Workers initiative, the Virginia Department of Corrections delivered substance use disorder treatment primarily through substance use treatment programs, groups, peer support, voluntary engagement, and through broader treatment contracts with contracted treatment providers. The agency also operated an MOUD program for incarcerated people who arrived on a prescribed medication or qualified for one inside. What was missing was a dedicated employee whose core job was to walk an individual with a substance use disorder all the way through their MOUD treatment and out to a community provider upon release.
On the COMPAS, approximately 66% of incarcerated people and those on community supervision screen as moderate or high risk for substance use disorder. Probation officers across 43 districts carry large caseloads and benefit from specialized partners who can assist with navigating the continuum of care for MOUD. Without dedicated addiction treatment referral staff inside the prisons, it was challenging to ensure a warm handoff to a community provider, or a SUD treatment professional on the other end, who would be waiting for the person to walk through the door.
In 2023, when the Virginia Opioid Abatement Authority began distributing opioid settlement dollars to state agencies, the VADOC capitalized on this opportunity to expand programming and staffing as a critical part of the Department's multidimensional response to the national opioid crisis. Executive Order 26 under The Right Help Right Now initiative gave the agency a clear policy mandate to strengthen substance use disorder services across the system to support opioid overdose prevention. In 2023 the agency had already defined the program's contours. For the first two years the program ran effectively alongside numerous Virginia overdose prevention initiatives. After 2 years of successful implementation in 2025, the program expanded from the initial 6 positions, into an 11-member team.
What They Built
The Virginia Department of Corrections built a dedicated team of SUD Social Workers, through a contracted SUD treatment provider's service, who are placed inside 12 correctional facilities. Each social worker is responsible for the substance use disorder case management piece for the people on their caseload, from initial screening through release. The team is overseen by the agency's statewide substance use disorder manager and a dedicated MAT Coordinator who along with the contracted provider, manages the social workers' day-to-day. As of year three, 11 SUD social workers are deployed across 12 sites, with one position split between Bland and River North to ensure coverage at those facilities as well.
The facilities currently staffed are Keen Mountain, Virginia Correctional Center for Women, Green Rock, Pocahontas, State Farm, Greensville, Nottoway, Haynesville, Indian Creek, River North, Bland, and Coffeewood. Site selection followed program need, the size of the substance use disorder population at each prison, and the existing infrastructure for substance use programs at each site. The footprint spans every region of the state and includes both men's and women's facilities.
Operationally, an SUD social worker screens referred individuals or those who request MOUD with the TCUDS, runs and co-leads group counseling and individual counseling sessions, supports interactive journaling and other recovery-oriented practices. Additionally, they serve as the navigator for medication for opioid use disorder. The social workers themselves do not prescribe; they connect people to the MOUD prescriber and stay with them through induction, stabilization, and release planning. They also coordinate with incarcerated peer recovery specialists, community treatment providers, and the probation district mental health clinician, who will support the person after release.
The reentry component is the part of the model that visibly closes the gap. The SUD social worker produces a substance use specific continuing care plan, that specifies the community provider, appointment date, and prior medication. The social worker refers the patient to the probation district's mental health clinician, so the district is aware of the referral and upcoming appointment. The Department consists of both correctional centers and probation and parole districts under one umbrella, allowing for one case management system to follow the client through the system. This allows the district staff to access program specifics during incarceration and during community supervision. Furthermore, under a data sharing agreement with the Department of Medical Assistance Services, Medicaid is automatically activated within 72 hours after release for eligible individuals. Where clinically indicated, the person leaves the facility with medication in hand, so the first community appointment is a continuation of care.
Who You Need at the Table
What made a willing partner essential vs. optional?
The required partners are the ones the model cannot function without. The Virginia Opioid Abatement Authority is required because it funds 100% of the work; without those settlement dollars, the program does not exist. A contracted SUD treatment provider is required because the existing treatment contract made it possible to quickly stand up an 11-person clinical team across 12 sites. The Department of Medical Assistance Services is required because the Medicaid auto-activation pathway is the single most reliable way to keep people enrolled in care after release. The prisons and probation districts are required because they are where the work happens. Community providers are required because they receive the handoff on release.
Helpful partners shape and strengthen the work rather than enabling it. Right Help Right Now set the policy frame. The Recovery Behind the Walls and Reentry to Recovery workgroups created the collaborative space where issues get surfaced and resolved. Virginia Department of Health helped start the Narcan box pilot. None of these is the reason a single referral form moves from a correctional center to a district; together, they are why the work continues to grow.
Budget Breakdown
What is the minimum viable budget to replicate this?
A state or local jurisdiction does not need a million-dollar program to replicate this. The minimum viable version is a dedicated SUD social worker, assigned to a specific facility or unit, whose only job is end-to-end substance use disorder case management. That single position, fully loaded with benefits and supervision, is roughly $75,000 to $100,000 a year, depending on region. A jurisdiction that begins with a one-position pilot, attaches it to an existing treatment contract, and tracks a small set of metrics (screenings, MOUD referrals, reentry plans completed, 90-day retention in community care) has the foundation to come back to a funder a year later with demonstrated need and demonstrated success.
What Worked and Why
Specific decisions or design features that drove success
Making the SUD social worker a dedicated, single-purpose role was the critical choice. Before the initiative, the case management piece was implicitly shared among staff from substance use programs, reentry planners, and probation officers. When the work belongs to everyone, the warm handoffs at release can get missed. Naming the SUD social worker as the person responsible for coordinating screening, counseling, MOUD navigation, and the SUD specific continuing care plan was the change that enabled the system to function as a continuum.
Hiring through the existing substance use disorder treatment contract holder, enabled the agency to quickly scale a SUD social worker team across 12 sites. Rather than running a new job posting for 11 state positions, and waiting through state hiring timelines, the team was added to an existing master contract with a vendor that already had the clinical management infrastructure. The same path is available to any state agency with an existing SUD treatment services contractor.
The Medicaid auto-activation pathway, built through a data-sharing agreement with the Department of Medical Assistance Services, addresses one of the most common needs for returning citizens. A person with Medicaid active within 72 hours of release can fill a prescription and attend a community appointment without first completing an application. Combined with medication in hand at release and a referral form to the probation district mental health clinician, the model ensures a clear transition to community systems of care.
Starting with a small year-one pilot to demonstrate outcomes, then returning to the funder for expansion, produced both the data and the credibility needed for year-three growth. The injectable buprenorphine pilot served 38 participants in year one. The first cohort of six social workers served 557 unique people in year one. Those numbers, paired with zero overdose deaths in DOC custody in FY2025, supported a year-three award that funded 11 positions and added the Narcan box pilot.
Active participation in the Recovery Behind the Walls and Reentry to Recovery workgroups under the Right Help Right Now executive order kept the initiative connected to the broader state opioid overdose prevention agenda. The governance structure surfaces issues across agencies (DOC, Medicaid, community providers, peer recovery networks). It resolves them in shared meetings rather than letting them sit unresolved at the seams of the system.
Early outcomes and data
Zero overdose deaths in DOC custody in FY 2025, down sharply from the prior year.
1928 unique people served year-to-date in year three, with hiring still in progress; 557 unique people served in year one, with the initial cohort of six social workers.
More than 1900 incarcerated people are currently on medication for opioid use disorder and are supported by SUD social worker navigation and continuation planning.
More than 1400 group and individual counseling sessions have been delivered year-to-date in year three, exceeding the goal of 400.
More than 800 peer recovery specialist connections have been made year-to-date in year three, against a goal of 400.
More than 700 substance-use-specific reentry continuing care plans have been completed year-to-date in year three against a goal of 200.
More than 1000 TCUDS screenings have been conducted year-to-date in year three, against a goal of 350.
The injectable buprenorphine pilot enrolled 38 participants in year one, demonstrating proof of concept that informed the design of a broader MAT program.
11 SUD social workers were placed across 12 facilities by year three, up from 6 in year 1 and 2.
For more than five years, the VADOC partnered with DMAS to implement a Medicaid auto-activation process that ensures eligible individuals leaving incarceration have active Medicaid coverage within 72 hours of release. While separate from the opioid abatement initiative, this statewide effort supports successful reentry and complements opioid abatement goals by improving access to treatment and care.
The Narcan box pilot was implemented across six probation districts, providing community naloxone distribution alongside in-prison work.
Lessons Learned
Role Clarification. SUD case management requires dedicated support. The SUD social worker is the person who stewards the process through all the key steps. These include the screening, the counseling, the MOUD connection, the continuing care plan, and the handoff. A clear, accountable team member is what turns a set of services into a continuum.
Pilot, prove, then expand. Money follows two things: demonstrated need and demonstrated success. The Virginia program began as a six-position pilot with an injectable buprenorphine demonstration. Year-one outcomes supported the year-three expansion. Asking for the full vision in year one can be the slower path.
Use the contract you already have. Adding SUD social worker positions to the existing SUD treatment contract was the fastest path to scale. Other state agencies with an existing health services or SUD treatment contractor may have the same option available to them.
Build the community handoff alongside the in-prison work. Counseling, MOUD navigation, and reentry planning inside the walls only translate to recovery when the handoff to the community provider, the probation district mental health clinician, and the active Medicaid record is real and confirmed before release.
Settlement dollars belong to the people most affected. The Virginia program directs 100% of its opioid settlement award to substance use disorder services for incarcerated people and probationers. Holding that line, year after year, is how settlement money becomes recovery rather than general operations.