Recommendations for Implementation

The position charged with transition planning varies among corrections systems.  In some jurisdictions, correctional staff provide both transition planning and case management services.  The most common arrangement is for prison staff to assume the lead role in transition planning, with some assistance from community corrections staff; once the inmate is released, community corrections staff assume the case management responsibilities.  Regardless of the specifics of the arrangement, collaboration between the various agencies and service providers who will be involved in the release, supervision, treatment, and support of the releasee is essential to a successful transition planning process.

Example:  Forensic Transition Team, Massachusetts Department of Mental Health

The Forensic Transition Team program was established in 1998 to provide transitional release planning services for offenders about to be released from correctional custody. The Forensic Transition Team conducts client interviews of inmates identified by mental health staff and coordinates appropriate community mental health resources.  Team members work with offenders at least three months prior to their release, providing them with case coordination and consultation to community providers for up to three months after release to address any obstacles to client community adjustment.  Arrangement of programs, treatments, and social support services is done in coordination with criminal justice officials to address public safety concerns.  The team collaborates both with institutional corrections authorities and with probation and parole officials to coordinate the linkages for offenders with mental illness to receive community-based services upon release.  The Massachusetts Department of Mental Health maintains a statewide database to track the progress of offenders served by the program, as well as to inform further program development and research efforts.^[2]

One particularly promising, albeit uncommon, strategy is to have the transition planner working with the inmate during the last months of his or her incarceration continue as a case manager (coordinating the delivery of services and facilitating the person's compliance with conditions of release) after the offender's release to the community.  As part of such a strategy, community-based agency staff, who will eventually provide postrelease case management, can be brought into the institution to work with institutional-based discharge planners in devising and carrying out a comprehensive case management plan.

Example:  Women's Discovery and Safe Release Programs, Rhode Island Department of Corrections

The Women's Discovery Program is a voluntary substance abuse treatment program offered to all women incarcerated in Rhode Island state prisons.  All inmates who spend at least 30 days in the Discovery Program are eligible for an additional component called Safe Release. The Safe Release Program provides mental health treatment services and specialized mental health discharge planning services to inmates with mental illness.  Case managers from a local community-based mental health provider, the Providence Center, work with corrections staff to oversee the discharge planning for these inmates as well as providing post-discharge case management services for up to one year, thus ensuring continuity of care.

Regardless for whom the transition planner works, it is essential that he or she be required to coordinate a team of people who, collectively, represent the agencies and organizations whose support and assistance are essential to the successful implementation of the transition plan.[3]  These agencies usually include, at a minimum, corrections, parole (or releasing authority), mental health agencies, housing, employment, health and welfare agencies and private providers of treatment and support services all have a part in the individual's life.

The collective participation of representatives of the community in the development of treatment plan - and their subsequent investment in its success - serves many purposes.  First, it encourages coordination between local outpatient services and correctional facilities.  Second, it promotes the mutual accountability of correctional administrators and mental health treatment officials for the treatment of offenders with mental illness.  Third, it facilitates the sharing of important information regarding the treatment history of the individual and his or her progress following release.

Missouri employs multidisciplinary teams to assess clients, plan interventions, and carry out services for parolees both in the institution and in the community.

Example:  Multi-disciplinary Team, Missouri Parole Board

The Missouri Parole Board has a staff person who sits on a team with institutional staff to develop a continued care plan for persons with mental illness.The continued-care plan is holistic in nature, addressing all areas of persons with mental illness offenders' life connected to his/her success in the community.  Once planned, the multidisciplinary team oversees the parolee's progress and the delivery of services.  The program consists of both an institutional and a community release center phase.  The institutional phase lasts for four months and selected inmates spend two months in the community phase for a combined minimum of six months.  The program is used by the parole board as a prerelease requirement as well as an alternative to revocation for those who are parole violators.

Successfully coordinating each of these teams and developing a transition plan that addresses the complex needs of people with criminal records who have a mental illness requires careful work and is extremely time consuming.  Accordingly, the ratio of individuals conducting discharge planning and case management services to releasees should be low, ideally with caseloads no higher than 20 releasees per supervision officer.

If possible, all parties, including the inmate, should participate in a discharge planning meeting just prior to the inmate being released.  This provides all parties with the opportunity to understand one another's roles and responsibilities set forth in the treatment and community integration plan, as well as to establish a working relationship to carry out the conditions of the arrangement. Ideally, family members should be part of this process. The offender or family may decline, however, especially if family members do not feel they are prepared to support the inmate upon his or her release.

Corrections systems have developed different approaches to ensure that an inmate's release into the community is gradual.  In many state departments of correction, inmates nearing their statutorily mandated release date or those who have been granted a parole are assigned to prerelease programs.  Some of these programs involve assignment to a prerelease housing unit either within a minimum-security unit or in a community-based setting (such as a halfway house).  Correctional discharge planners assigned to these programs help make community contacts and referrals for housing, employment, and services.

Transition planners' responsibilities include assessing offenders' needs and strengths and facilitating linkages to appropriate community-based services.  Given the special needs of this population, transition planners need to be aware of what services are available in the jurisdictions they serve and which community-based mental health and habilitation services are necessary for the care and treatment of people with mental illness.

While institutional release planning staff reach out to identify resources in the community, it is equally important to establish a working relationship between the offender and a community mental health provider prior to his or her release to ensure continuity of care.  As discussed above, encouraging and facilitating providers' access ("in reach") to the facility will foster community linkages and increase the likelihood that the offender will be engaged and served effectively upon his/her release from the institution.

Example:  Dangerous Mentally Ill Offender Program(WA)

In 1999 officials in Washington State enacted legislation regarding "dangerous mentally ill offenders" released from Department of Corrections (DOC) facilities.  The statute directed the Department of Social and Health Services (DSHS) and DOC to work together to expedite financial and medical eligibility for the offender and establish interagency teams for pre-release planning.  The interagency planning teams include DOC Risk Management Specialists, a community corrections officer, a representative of the relevant Regional Support Network (RSN), representatives of community-based mental health and substance abuse providers, family members, and law enforcement.  The interagency team begins to develop comprehensive release plans at least three months prior to release, including detailed plans for the 48 hours postrelease, service plans (housing, treatment, etc.), victim services, financial resources, and community corrections information.  Case managers, community-based mental health and chemical dependency providers, and community corrections officers visit the offender where he or she is incarcerated, facilitating the development of relationships prior to release.

The case management plan should include dates, times, and locations for follow-up appointments with community supervision agencies and for appointments with treatment providers.  Mental health case managers also can then be on hand to ensure that the releasee is engaged in the planned treatment and service programs and to monitor the initial delivery services.

Since such a large proportion of offenders with mental illness also have histories of substance abuse, it is likely that the community transition and case management plan will also include provision for substance abuse treatment (see Policy Statement 17: Receiving and Intake of Sentenced Inmates, for more on co-occurring disorder statistics in prisons; also see Policy Statement 37: Co-Occurring Disorders).  Substance abuse treatment services may be provided at one site as part of a comprehensive program for dually diagnosed offenders.  If substance abuse treatment is to be provided off site and/or by a separate agency, or if the releasee is to participate in 12-step or other community-based fellowship programs, the community-based case manager should also make arrangements for the offender to receive escort to initial meetings and appointments and ensure that engagement has occurred.  Twelve-step fellowship programs, such as Alcoholics Anonymous and Narcotics Anonymous, provide escort services as part of their regional World Fellowship Networks.  These organizations list local groups and fellowship networks in the white pages of regional phone books.

At a minimum, discharge planners can facilitate case conferences that include participating treatment and social service providers as well as the offender. When face-to-face case conference is not feasible (for instance, due to prohibitive distances between the institution and the home community), it may be conducted as a teleconference. A number of jurisdictions recognize the importance of case conferencing, and have taken steps to make sure that it occurs.

Adequate housing is the linchpin of successful reentry for offenders with mental illness.  Housing, especially when it is combined with support services, provides a stable base from which individuals can access treatment in the crucial days immediately succeeding release.  Every person with mental illness leaving jail or prison should have in place an arrangement for safe housing (or, at the least, shelter).

Unfortunately, locating suitable housing for their clients is one of the greatest challenges for discharge planners and community-based case managers (see Policy Statement 38: Housing).  They will need to know what type of housing arrangements are available in the communities they serve; how to make the appropriate connections between the offender and the landlord; and what provisions there are for indigents unable to pay the rent.  Perhaps even more important, the discharge planners and community case managers must know how to overcome explicit or implicit prejudices and exclusions based on either mental illness or criminal history.  For example, individuals convicted of certain violent, drug-related, or sex-related offenses are not eligible for federal housing subsidies.[4]  Transition planners are likely to encounter considerable resistance from private-sector individuals and agencies, and, to be effective, will have to assume the role of housing and social services advocate for the releasee.  At least one jurisdiction is developing a program to address this crucial issue.

Example:  Parole Support and Treatment Program (PSTP), Project Renewal, New York City (NY)

Project Renewal is a New York City based nonprofit that provides an array of services for individuals who are homeless and have mental illness and substance abuse problems.  The Parole Support and Treatment Program is a joint effort between Project Renewal, the New York State Office of Mental Health, and the New York State Division of Parole.  The PSTP will provide 50 new units of transitional, supportive housing and intensive clinical services to newly released parolees who suffer from serious and persistent mental illness and co-occurring substance abuse disorders.  The program will combine an "ACT-like" treatment team and 50 scattered-site supported transitional housing beds.  During their time in transitional housing parolees will work with the clinical team to transition into permanent housing, ranging from community residences to Section 8 apartments.

All individuals with serious mental illness leaving jail or prison should be physically transported to their housing arrangement or shelter and provided with a short-term supply of medication and a prescription (or provision) for long-term supply.  In such cases, the mental health agency assigned to provide the offender with community services is the appropriate agency to provide transport from the jail or prison to the place where the offender will reside.

Offenders should have an adequate supply of essential psychotropic medications upon their release.  They should be given at least a seven-day supply and prescriptions sufficient for the period up to when entitlements may reasonably be expected to be reinstated, typically within 90 days after release to the community.  States that contract with private correctional health care providers for the provision of institutional health care should include in their contracts a requirement that these extra medications are provided to discharged inmates.  Also, if it has not already been done by agents of the detention or corrections authority, the community-based agency or case manager responsible for the released offender should take steps to reinstate the individual on Medicaid in order to pay for necessary medications.

Community-based mental health providers are reluctant to provide services to people with criminal records for numerous reasons.  Near or at the top of this list of reasons is this population's inability to pay for treatment.  State and county government officials attempting to control the explosive growth of health care expenditures routinely warn providers about delivering services to individuals who ultimately do not qualify for federal benefits; providers will not receive back-payments for the delivery of these services.  Given the crushing demand that they are attempting to accommodate, providers are understandably hesitant to deliver services to a person who does not have health insurance and whose eligibility for public benefits is not immediately apparent.

Corrections administrators and health officials can take several steps to facilitate inmates' participation in federal benefit programs. (see Appendix C: Explanation of Federal Benefit Programs) First, state officials should require corrections staff to distribute to inmates information and application forms for all relevant federal and state benefit programs, including Medicaid; federal SSI and SSDI benefits; Temporary Assistance to Needy Families (TANF); food stamps; veterans programs; and state general assistance.  Staff should provide additional assistance, and in general pay particular attention, to subsets of the inmate population with mental illness who are especially likely to qualify for benefit programs, including those who meet the following criteria: 1) received federal benefits at the time of incarceration; 2) have very low incomes, particularly those under age 21; 3) are veterans; or 3) are parents of children under 18 and likely to be custodial parents upon release.

Example:  Partners Aftercare Network (SPAN), San Bernadino (CA)

This initiative established a multi-agency team whose purpose is to link inmates with serious mental illness to needed mental health services upon their release from jail.  The aftercare management team serves as a "bridge" between custody and community integration by providing, among other things, financial advocacy to assist clients in obtaining Social Security and medical and other benefits.

Second, appropriate authorities should establish a process through which the state Medicaid agency will accept applications from inmates while they are still in custody and will process these applications in a timely manner to ensure that those found potentially eligible are then able obtain access to the benefits immediately upon release.  Corrections administrators must appreciate the difficulty in timing a person's participation in benefit programs.  Accordingly, corrections officials should inform local social security offices and the state Medicaid agency as early as possible of the exact date of release of inmates who qualify, or may qualify, for benefits.

Example:  Medicaid Reenrollment for Inmates at Hamden County CorrectionalCenter (MA)

At Hamden County Correctional Center, discharge planning begins at least three months before an inmate's scheduled release.  The mental health treatment division in the jail employs one social worker who focuses on discharge planning for inmates with mental illness. The discharge planner helps inmates to apply for Medicaid, SSI, Mass Health, and other appropriate entitlement programs.  The goal is to have inmates considered eligible for entitlement programs at the time of their release.

In establishing this process, corrections administrators should work with local mental health authorities to arrive at an agreement regarding diagnoses of people who are disabled and therefore may be eligible for SSI (and, by extension, Medicaid).  Corrections administrators should also assist inmates in applying for state identification cards, which will be provided upon the inmate's release.  Without such proof of identification, it is nearly impossible for a person to avail him or herself of many benefits or services.

The vast majority of states have a statute or a constitutional amendment requiring that the victim be notified before the offender is released from prison.^[5]   Regardless of whether the inmate to be released has a mental illness, releasing authorities and correctional staff must comply with victim notification requirements.

Efforts should be made through correctional crime victim specialists and community-based crime victim agencies to reach out to crime victims and inform them of the pending release date of those who have victimized them, to educate them as to the decisions being made on behalf of the offender, and to provide them information about the measures being taken to ensure their safety.

Successful implementation of the transition plan is usually contingent on the following:

• updated examinations, which closely reflect the status of the inmate's mental health and psychotropic medication requirements on or near the release date;
• cooperation among at least two agencies to enable representatives from one agency to navigate another system credibly; and
• provision of a mental health status evaluation for the purpose of risk assessment and/or supervision. (See Policy Statement 19: Subsequent Referral for Screening and Mental Health Evaluation.)

A mental health professional should conduct a mental health assessment of the inmate at a point just prior to release to ensure that the discharge plan is fully adequate to addressing the inmate's current needs and circumstances.  If it is not, the mental health professional should work with the releasing authority to modify the discharge plan accordingly.

Approximately one out of every five sentenced inmates in the United States is released from a correctional facility without any continued community-based supervision.[6] These inmates complete their sentence in prison because, through the abolition of parole and other measures, state law prohibits the release of an offender from prison before his sentence is completed or because releasing authorities denied the inmate's request for release.  Due to disciplinary histories and reluctance of authorities to release people with mental illness to the community before their sentence has expired, issues discussed earlier in this report, the percentage of inmates with mental illness who complete their sentence while in prison is probably greater than the 20 percent figure that applies to all general population inmates. [7](See Policy Statement 20: Release Decision.)

Offenders with mental illness released to the community without community supervision are particularly difficult cases to manage, both because supervision and participation in treatment and social service programs are completely voluntary and because many newly released offenders resist services and treatment. For those releasees who are unwilling to seek traditional mental health system services, an approach to consider is to link them to consumer-run programs, like a drop-in center, or to create peer (i.e., individuals with mental illness who has themselves once been incarcerated) contacts for outreach.  Such programs or outreach provide contacts, appropriate socialization experiences, and can link individuals to services once they are ready. (See Policy Statement 39: Consumer and Family Member Involvement.)

Releasing authorities should strongly encourage offenders with mental illness to continue services after release, as well as encourage the community mental health programs as much as possible to conduct active monitoring and outreach to recently released offenders referred to them and otherwise attempt to provide such services.

Absent criminal justice oversight and supervision, referral to community-based mental health case management and advocacy programs is perhaps the best recourse.  Again, reaching out to community-based organizations and agencies that would serve this population and facilitating their access to the institution/inmate prior to release will enhance the likelihood that an individual, upon release, would seek out services.  It is also an attractive alternative to and adjunct of criminal justice supervision since community mental health case management services are often eligible for Medicaid reimbursement.  (See Chapter VII:  Elements of an Effective Mental Health System, especially Policy Statements 36, 37, and 39, for further discussion of mental health case management services.)