In keeping with the general considerations of training, monitoring, and equity discussed in the previous section, there are also several specific best practices to keep in mind for providing the effective interventions we have discussed in this chapter. These include creating a single, unifying case plan; engaging in pre-release preparation; providing in-person community guidance; directing a range of services; and preparing for re-incarceration. Each of these is discussed briefly in this section.

Unifying Case Plan

A case plan for reentry should include goals, timelines, and the supported person’s responsibility to meet them. The plan should also clarify the person’s risk level and needs and share the services they are receiving, including those related to mental disorders. When substance use is a concern, plans should include relapse prevention approaches and connections to treatment or recovery supports. Finally, the plan should contain probation/parole requirements, outstanding warrants in other jurisdictions, child support orders, and any other information relevant to the conditions of a person’s release.

The person receiving services should provide input on their case plan. The more collaborative the process of creating a case plan and setting goals, the more likely a client will be committed to achieving them. All agencies and organizations should use the same case plan. This requires interagency collaboration and ongoing sharing of information to ensure details are current and everyone is working toward the same goals.

Sometimes, the sharing of information—particularly matters of health care and mental health—can create privacy concerns. Many people are vaguely aware of the requirements of federal and state laws that are intended to protect patient privacy, primarily the law known as HIPAA—the Health Insurance Portability and Accountability Act of 1996. Under HIPAA, health entities (like providers and insurance companies) are prohibited from sharing patient information or records without permission. Those healthcare providers and their associates are called “covered entities,” and covered entities must be cautious in how they share any protected health information (U.S. Department of Health and Human Services, n.d.). Thus, HIPAA is sometimes a barrier to agencies sharing information to create continuity of care. Nevertheless, those barriers are important to protect confidential health information.

In the criminal justice context, HIPAA is sometimes perceived as a barrier when it is not. Therefore, criminal justice professionals need to be aware of the rules that apply to them and understand what does not apply to them. For example, probation officers sharing information is generally not restricted by HIPAA; the information they share is part of the legal system, not information shared by a health-care entity. Likewise, police officers, employers, and schools are not HIPAA-covered entities, although other laws may apply to ensure the privacy of certain records (U.S. Department of Health and Human Services, n.d.).

Preparation and Rapport

Case managers, peer support workers, and patient navigators who engage with a person in custody have an opportunity to build rapport and facilitate continuity of care as people move from jail or prison to the community. This step is sometimes called in-reach. In-reach may be a single visit immediately preceding release, or it may involve multiple visits a few months before release. In-reach is especially effective if conducted by the same provider who will work with the person post-release. In-reach meetings can focus on rapport building, re-screening/assessing the person, and reviewing and updating an existing case plan. If prison or jail reentry staff did not create a case plan, the case manager, peer, navigator, or treatment provider can create one as part of their in-reach activities.

People leaving prisons and jails, especially those living with mental disorders, are extremely vulnerable to poor outcomes in the initial period following release. Outcomes improve when people have what they need to support their physical and mental health immediately upon leaving the facility. For example, at release, a person who uses medications should receive a supply of any prescribed medication as well as an active prescription that will last them until their first appointment with a provider. This includes medications for mental health conditions and substance use disorders, as well as any chronic illnesses (e.g., diabetes or asthma). Additionally, people being released from custody should have a government-issued photo identification, which will allow them to obtain treatment, support services, and government benefits.

In-Person Community Connections

Case managers and peer and patient navigators can play an important hands-on role at release by physically meeting clients, providing access to transportation to ensure they get to their first behavioral health treatment appointment or residence, and ensuring they have what they need when they leave. These steps increase the likelihood that a person engages with treatment services.

One way to provide hands-on support (figure 8.15) is with a “welcome to the community” experience. A “welcome to the community” experience is structured, supportive, and proactive in avoiding risks for re-incarceration. A case manager, peer support worker, or patient navigator is best suited for these guided experiences, which may involve picking up the client at the facility and “walking with them” through the first hours (and even days) after release. Ideally, this same support provider already provided in-reach services to the incarcerated person pre-release and became a trusted partner. A “welcome to the community” can include ensuring the recently released person has clothes that fit and do not look like they were issued by the prison, transferring cash the person had in their account at the facility (so they do not have to cash a check or pay fees to use a debit card), and supplying hygiene items and food to meet immediate basic needs.

People living with mental disorders who are reentering community life from prison or jail will be accessing behavioral health and often other health treatments. Linking or connecting a person with care at the appropriate level of treatment (e.g., outpatient, intensive outpatient, inpatient, residential) based on an individual’s assessments and case plan is critical. With the appropriate permissions and information waivers, case managers, peer support workers, or patient navigators can make the initial linkage to a treatment provider on behalf of a client (making the appointment or informing the provider someone is coming in). Case managers, peer support workers, or patient navigators can then provide a warm hand-off to these providers in the community. A warm hand-off involves directly introducing the released person to the receiving provider, ensuring the person has all the necessary information to continue services, and, if appropriate, even attending an initial appointment to advocate and hear information. Understanding the conditions of a person’s probation or parole that may affect access to services, such as the distance from home they are allowed to travel, is imperative to providing people with access to care that will not violate the conditions of their release.

When a recently released person misses appointments, a reentry provider can and should proactively follow up with the person. Timely reengagement is critical, and case managers, peers, or patient navigators should conduct home, shelter, or residential treatment visits whenever possible to help the person reengage in services. For those who are unstably housed, this may mean seeking the person out where they stay most often. To provide this level of follow-up, appropriate releases of information must be in place authorizing treatment providers to contact case managers, peers, or patient navigators if a person misses an appointment.

Range of Services

After release from custody, an entire range of support services—including housing, employment, medical care for chronic health conditions, family reunification, and access to government benefits—can be critical to a person’s successful reentry. Case planning and peer support can help people engage with all of these services as soon as possible upon entering the community.

Housing is one of the most significant needs for individuals reentering the community. For people who have substance use disorders, housing should meet the recovery and support needs of the person, whether that means living alone or with friends or family, in a halfway house, or in supportive housing. Case managers should be aware of community housing or shelters that do not accept individuals using MOUD or MAUD. For some people, reentry involves community placement (e.g., at a halfway house) while they are still serving sentences and under criminal justice supervision (probation or parole).

Reentry programming can also help a person secure employment with a livable wage (figure 8.16). Many people reentering the community from jail or prison face barriers and stigma associated with their involvement with the criminal justice system, sometimes in addition to the challenges associated with experiencing a mental disorder. Case managers can connect individuals to supported employment and community-based employment programs. Community-based employment programs provide job training, job resources, and job placement services. Reentry programs can also create explicit pathways to hire former or existing clients as peers or help connect them to other reentry or recovery programs that hire peers with lived experience.

Supported employment, an evidence-based intervention, provides job development and placement, job coaching and training, and problem-solving skills development to people with disabilities and behavioral health conditions. Reentry programs can help identify supported employment providers through a local Department of Vocational or Rehabilitation Services database, the Veterans Health Administration, a state mental health agency, and/or the Social Security Administration. The Social Security Administration’s free Ticket to Work [Website] Program supports career development for people ages 18 through 64 who receive Social Security disability benefits and want to work. The Ticket to Work Program is intended to help people with disabilities move toward financial independence (Social Security Administration, n.d.).

For many people leaving prison or jail, a positive connection to family is important to successful reentry. Case managers and peers can connect a person with family reunification resources, when appropriate. This may include family counseling, parenting assistance, childcare, and other reunification services when restraining orders are not present. Case managers and peers should assist the people they support in identifying family members with whom it is safe to reconnect. People without supportive family members should foster positive healthy connections with friends, peers, and mentors.

For people living with serious mental illnesses, such as schizophrenia, reentry service providers can offer intensive mental health services, some of which were discussed earlier in this text, such as Forensic Assertive Community Treatment (FACT). The FACT model, discussed more in Chapter 5, provides all-hours access to comprehensive services delivered by a multidisciplinary mental health and criminal justice team. Individualized psychiatric treatment and recovery support services address the immediate needs of people living with serious mental illness and provide services that address criminogenic risks and needs.

Preparation for Re-incarceration

Re-incarceration is a reality that reentry programs need to anticipate (figure 8.17). In the period immediately after release from prison or jail, people have an increased risk of re-arrest and re-incarceration. The highest rates of re-arrest occur in the first year post-release. If this occurs, reentry providers can support the person’s connections to treatment while they are incarcerated. If possible, conducting in-reach or providing additional information to prison or jail staff can help ensure the re-incarcerated person maintains some level of treatment or support while incarcerated.

If re-incarceration is for an extended duration, a closure session should be provided along with a plan for how to reengage the person upon their next release. In cases where re-incarceration is short, such as a brief jail stay, reentry staff may be able to reengage the person with the same staff at their next release. Providing a reconnection to the same staff and treatment providers will help smooth the person’s next transition into the community.

Licenses and Attributions for Best Practices for Reentry Programs

Open Content, Shared Previously

“Best Practices for Reentry Programs” is adapted from Best Practices for Successful Reentry From Criminal Justice Settings for People Living With Mental Health Conditions and/or Substance Use Disorders by Substance Abuse and Mental Health Services Administration (SAMHSA), which is in the Public Domain. Modifications, by Anne Nichol, licensed under CC BY 4.0, include condensing, revising and expanding the content.

Figure 8.15. Photo by Centre for Ageing Better is licensed under the Unsplash License.

Figure 8.16. Photo by Ahsanization ッ is licensed under the Unsplash License.

Figure 8.17. Photo by Basil James is licensed under the Unsplash License.