Same-Day Buprenorphine Care for Justice-Involved Adults
A Low-Barrier, Walk-In Model Pairing Justice Outreach with Co-Located Medical Care for People with OUD
In Burlington, Vermont, a justice outreach organization, Vermonters for Criminal Justice Reform (VCJR), and a primary care clinic, Johnson Health Center, run a walk-in, low-barrier care model that meets people with opioid use disorder where they are. It pairs trusted street-level engagement with same-day medical care, buprenorphine prescribing, and wound care, all delivered in one co-located storefront for justice-involved adults who do not fit the traditional appointment-based system.
The Challenge They Were Addressing
In Burlington, a small but visibly homeless population of adults with opioid use disorder was cycling through the criminal justice system, the emergency department, and a patchwork of outpatient programs that asked them to keep scheduled appointments, sit in clinic waiting rooms, and complete paperwork before being seen. Approximately 90 percent of the people the team now serves are living outside, many carry warrants, and most have years of difficult medical experiences behind them. The traditional appointment-based system was missing them, and they were missing it.
The clinical picture was getting worse at the same time. VCJR, a walk-in drop-in serving justice-involved adults, was seeing a sharp rise in xylazine-related wounds, untreated infections, and people developing endocarditis because there was no reliable point of medical access between the street and the emergency department. Buprenorphine prescribing was concentrated in clinics that required intake processes incompatible with the realities of unsheltered life, and the local methadone clinic only admitted new patients early in the morning, with no public transit option for many of the people who needed it most.
VCJR's co-director, who is open about her own lived experience of opioid dependency, called a nurse practitioner she trusted at Johnson Health Center, a small primary care clinic, and asked whether she had any capacity to see people at the VCJR storefront. The answer was a Tuesday pop-up with a toolbox of medical supplies. Demand was immediate and unmistakable. Within months, the two agencies were operating a co-located walk-in care model, and they applied for opioid settlement funding to formalize and expand what the community had already shown it needed.
What They Built
The program runs out of two adjacent storefronts in downtown Burlington: VCJR's walk-in drop-in for justice-involved adults, and Johnson Health Center's low-barrier medical office next door. People come in for whatever they need: a snack, wound care supplies, a ride to treatment, help with a warrant, naloxone, clothes, or simply a familiar face. They are not asked to schedule an appointment, present an insurance card, or sit in a waiting room. Once inside, they encounter both organizations working side by side: VCJR case managers who already know them, and a nurse practitioner who can prescribe buprenorphine, treat a wound, or call in a bridge prescription for someone newly released from jail.
Buprenorphine prescribing is the clinical anchor. Johnson Health Center offers the full range of products, including Suboxone, daily sublingual buprenorphine, and Sublocade injectables. The team works to move people toward injectables where appropriate, so daily medication management becomes one less obstacle. For patients who need or prefer methadone, the program helps them get into the local opioid treatment program, including arranging transportation to early-morning admission windows. Wound care, antibiotics for soft-tissue infections, and mental health medication management are delivered in the same visit, often in whichever space is most comfortable, including the VCJR drop-in floor when the medical office feels too clinical.
The two organizations are deliberately a one-stop shop. VCJR case managers act as connectors and advocates: they help clients navigate probation and parole, sign releases, communicate with public defenders, accompany clients to medical appointments and to the emergency department, and coordinate bridge prescriptions when people are released from incarceration. Johnson Health Center provides medical care and bills Medicaid where it can. It keeps antibiotics and wound supplies on hand so that someone with a serious soft-tissue infection does not have to clear the practical and psychological hurdle of walking into a pharmacy. The medical clinic is open two to three days a week in the VCJR space, and the case management team is there every day.
The program is closely integrated with Vermont's correctional medication-assisted treatment system, one of the strongest in the country. Every person entering the Vermont Department of Corrections is screened for opioid use disorder within 24 hours and started on buprenorphine or methadone within 48 hours. The team has built standing relationships with probation officers, public defenders, the Howard Center substance use testing program, and the corrections medical contractor so that someone leaving incarceration can come directly into the drop-in, secure a bridge prescription, and stay on their medication during the chaotic first days of reentry.
Key Program Components
Who You Need at the Table
What made a willing partner essential vs. optional?
The required partners are the ones whose participation makes the model possible at all. VCJR and Johnson Health Center are required because the entire premise is the daily co-location of justice outreach and primary medical care; remove either, and the model collapses into a referral, which is exactly the arrangement this population has already shown it cannot use. The Vermont Opioid Settlement Advisory Committee is required as the funder. The Department of Corrections and its medical contractor are required because the population is constantly moving between the community and incarceration, and continuity of medication across that boundary is the difference between recovery and overdose. Probation, public defenders, the court, and the local methadone clinic are required because they hold the practical pieces of justice and treatment access the program must coordinate every day.
Helpful partners extend the model rather than enabling it. The hospital and emergency department are essential to specialty care, but the program operates regardless of whether those relationships are formalized. Established buprenorphine providers accept routed referrals and exchange notes, protecting clinic capacity and avoiding duplicated care for stable clients. The Howard Center, community donors, and the Opioid Response Network all strengthen the program; none of them is the reason a client walks through the door.
Budget Breakdown
What is the minimum viable budget to replicate this?
A community that already operates a walk-in or drop-in serving justice-involved adults can layer this model on for approximately $150,000 to $250,000 per year, depending on the amount of medical provider time needed. The non-negotiable line items are: one dedicated case management position to handle advocacy, accompaniment, and coordination with the justice system; part-time medical provider time (ideally a nurse practitioner or physician assistant who can prescribe buprenorphine) at one to three half-days per week; a small flexible fund for stock antibiotics, wound care supplies, and client transportation; and adequate clinical liability insurance for the new service line. Site costs can often be absorbed by an existing drop-in if there is space for the medical provider to see clients privately.
What Worked and Why
Specific decisions or design features that drove success
The single most important design decision is co-location: medical care delivered inside the outreach site rather than through a referral to a separate clinic. Other communities have tried to fix the access gap by referring clients from outreach into clinic appointments, and the referral chain breaks at every step. Putting the medical office next door, in the same building footprint as the drop-in, eliminates the handoff and makes a medical visit feel like an extension of a conversation rather than a separate appointment.
Shared philosophy between the two agencies is what makes co-location actually work. Both organizations operate with the same posture toward clients: tolerance for challenging behavior, no judgment about ongoing use, no expectation that clients arrive on time or with paperwork in order, and a willingness to meet medical care in whichever space feels comfortable. When VCJR's co-director explicitly hands her trust to the nurse practitioner during a first visit, she is staking her own credibility on the partner agency, and that only works because the agencies share values from the start.
Settlement dollars, allocated almost entirely to direct service staffing, kept the model lean and replicable. The agencies deliberately avoided spending the awards on furniture, software, or large startup procurement; community donations covered fixtures, and the hospital donated wound care supplies. The result is a budget profile another small community can plan around: a case management position and a part-time medical provider, with everything else either donated or billed.
Buprenorphine across the full product line, especially Sublocade injectables, removed daily medication management as a barrier for clients living unsheltered. Daily dosing requires a level of predictability that most clients lack. The team transitions clients to monthly injectables when clinically appropriate, which stabilizes them enough to engage with the rest of the model.
Routing stable clients back to their existing primary care providers helped prevent the model from being overwhelmed and kept the local provider community from feeling displaced. By asking every new client whether they have a medical home and bridging back when appropriate, the program signaled that it was built to fill a specific gap rather than compete with the existing system. That posture earned the program standing relationships with the other buprenorphine providers in Burlington and with the local hospital.
Early outcomes and data
Year 2 added more than 170 new patients, exceeding the initial growth target of 50 and more than tripling the planned expansion.
More than 800 patient visits in the most recent program year, with active growth in the office-based buprenorphine caseload.
Identified by a major Vermont buprenorphine prescribing entity as the only growing office-based buprenorphine program in Chittenden County, the largest county in the state.
Retention on buprenorphine in the low-barrier walk-in model, as reported by the clinical team, exceeds retention rates observed in standard appointment-based outpatient practice.
Documented coordination with the Vermont Department of Corrections on bridge prescriptions for clients leaving incarceration, including unanticipated court releases and bail outcomes.
Sustained engagement with a population that is approximately 90 percent unsheltered and has near-universal opioid use disorder, with clients frequently returning to the same site for repeat care.
Lessons Learned
Co-locate; do not co-refer. The single most consequential design decision is to place the medical office within the same building footprint as the outreach storefront. A referral, even a warm one, asks the client to navigate a transition this population has already shown it cannot reliably make.
Shared philosophy is the non-negotiable. Two agencies can share a hallway and still fail if they hold different beliefs about how to treat clients. The model works because both teams answer the same way when a client arrives with a wound, a warrant, and no appointment.
Start small and let demand build the case. A one-day-a-week pop-up that grew into a full clinical practice is more credible to funders, partners, and clients than a fully built program announced in advance. Demand is the data.
Spend the award on people, not stuff. Direct service staffing is the highest and best use of settlement dollars. Furniture and fixtures can be donated; medications and supplies can be partly billed or absorbed. Every dollar spent on personnel goes to the bedside.
Plan for the funding gap you can already see. Settlement funding in Vermont is year-to-year and not guaranteed. The program is building Medicaid revenue, foundation relationships, and an appeal strategy so the model can survive a funding cycle without an award.