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The Problem:

Research in public mental health services has identified continuity of care as a critical component in effective treatment. Comprehensive community mental health systems have developed effective approaches to engaging individuals and providing continuity of care, including case management, psychiatric rehabilitation, continuous treatment teams, assertive community treatment, and new approaches to integrated treatment of individuals with co-occurring mental illness and substance use disorders. These practices, along with advances in psychopharmacology, offer hope of effective and ongoing treatment for many individuals who were previously considered untreatable.

Many of the individuals most in need of mental health and dual diagnosis services become involved in the criminal justice system. They may be in treatment at the time of their arrest, but it is more likely that they have previously been untreated, or have discontinued treatment. They may be arrested because of behaviors that result from their deteriorated psychiatric condition. They often have many cycles of arrest, release, deterioration, and re-arrest. Even though significant improvements in treating and serving persons with mental illness have been developed, in most communities persons with serious mental illness do not have sufficient access to these advances. There is resistance among community mental health providers to working with individuals with criminal histories, and in corrections there is resistance to working with persons with serious mental illness. Consequently, any effective solutions to the problems addressed here will require an integrated effort across the boundary between the criminal justice system and the behavioral health system.

For some individuals, their mental illness may first be identified and treated during incarceration. Appropriate treatment and aftercare could change the course of these individual's lives. However, on release from jails there is often no systematic attempt to facilitate follow-up treatment and continuity of care. For those who are receiving treatment at the time of arrest, the mental health team in the jail may attempt to continue the treatment that was initiated in the community. However, there may be no communication with previous caregivers, and because of the unavailability of medical records, facility rules or formulary considerations, the medications that were prescribed in the community may not be continued. On release, there is no organized attempt to facilitate reconnection. To the extent that no connection is made to post-release treatment, these individuals are once again "lost to follow-up," and are at risk for deterioration in their psychiatric condition and behaviors that lead to re-incarceration. A more comprehensive and effective approach to continuity of care is needed.

Since continuity of care is an essential and integral component of effective mental health treatment, it is imperative that any psychiatric treatment provided during a period of incarceration include planning for post-release follow-up care in the community.

The American Association of Community Psychiatrists, through its Committee on Persons with Mental Illness Behind Bars and its Committee on Continuity of Care and Discharge Planning, has developed the following standards for post-release planning.

RECOMMENDATIONS:

1. When appropriate, every effort should be made to divert mentally ill offenders from correctional settings. Uniform, effective methods should be developed for screening and identification of inmates with mental illness. In addition, sufficient resources must be allocated to correctional facilities to provide mental health treatment to inmates.

2. Release planning is an important component of the treatment plan and should begin at the time of admission. Rigorous planning for post-release mental health services must be set in motion at the time of admission and/or identification of a psychiatric condition, and not left to the last minute just prior to the individual's release. Furthermore, the court system or inpatient facility must take into account that adequate time must be provided to the releasing facility in order for a comprehensive community-based disposition plan to be in place.

3. For persons who are homeless, referral to an assessment shelter (alone) following release does not constitute an adequate plan. Jail mental health services should make specific treatment referrals. Direct referral to treatment shelters should be made possible, and policies such as those requiring individuals be sent to an assessment shelter first (where treatment is not adequate), should be adjusted accordingly. A common assessment form to be used by the jail mental health services and homeless services would obviate the need for an extra assessment and the consequent delay in beginning treatment.

4. Funding for care following release should be facilitate by assessing insurance status (including Medicaid, SSI and other government entitlement programs) and program eligibility. This assessment should be performed at the time of admission and well in advance of anticipated release from jail. Serious efforts must be made to have social service, disability and medical benefits active at the time of release. The courts, probation department and jail mental health staff should work with DSS and other agencies that manage indigent health benefits to avoid revocation of all benefits when an individual enters jail. Instead, a temporary suspension of benefits should occur when the individual is admitted to the jail, with reinstatement at the time of release. DSS and the jail release planner must cooperate in a way that will ensure that the patient will have immediate access at the time of discharge to benefits that will pay for all necessary treatment services, as well other benefits such as cash and food stamps to provide for basic survival needs. State policy should be amended to prevent individuals who are briefly incarcerated from being removed from state-run health and benefit plans. And for those not enrolled, SSI and SSDI benefit applications should be initiated while the offender is incarcerated. Special efforts should be made to engage the Veterans Administration in determining eligibility and providing services to qualified veterans.

5. Release planning should be multidisciplinary and comprehensive and include plans for psychiatric treatment (including outpatient, psychiatric rehabilitation, dual diagnosis and case management), social services (e.g., housing, food, vocational rehabilitation), medical, veterans benefits and services, and nursing services that will be necessary following release. The individual or agency to provide a case management function must be clearly identified. Community psychiatric referral must include consideration of appropriateness of program based on the underlying clinical diagnosis, and the condition and special needs of the individual. Examples include specialized dual diagnosis programs and more structured high intensity programs for the forensic population. The appropriateness of specific placements should be determined in consultation with the outpatient team.

6. If probation or parole is involved, the officer should receive complete information about all referrals. Officers should be encouraged to work with mental health providers to develop alternatives to incarceration in response to future psychiatric episodes. There should be a specialized PO who has added mental health expertise, and who works with clinicians who have forensic or correctional experience, i.e. cross training. (See Roskes E, Feldman R, Arrington S, Leisher M: "A Model Program for the Treatment of Mentally Ill Offenders in the Community," Community Mental Health Journal 35:461-472, 1999; and Roskes E, Feldman R: "Treat or Monitor? Collaboration Between Mental Health Providers and Probation Officers," Correctional Mental Health Report 1(5):69-70, 2000.)

7. Inmate input into the release plan must occur, and the individual must be included from the beginning. For example, the inmate can be enlisted, with supervision, in making phone calls to set up aftercare appointments. As the psychiatric condition improves during the course of treatment, the individual should be encouraged to assume an increasingly greater share of the responsibility for the plan that will assure ongoing and continuing care following release.

8. Family input into the release plan should occur to the extent that family is involved and the inmate identifies and wishes for a family member(s) to be involved. All potential sources of community-based support should be enlisted to help the transition back to the community. The family/primary support system should be notified of the inmate’s release prior to the release date.

9. A clinician, team or individual at the Outpatient/Community Agency should be identified as being responsible for the coordination/provision of community care following release. They should be identified, contacted, kept informed, and actively involved in the release plan. Incentives should be created for community providers, rather than jail workers, to do outreach (or "inreach") to the jails and begin the engagement process prior to release.

10. Efforts should be made to make it as easy as possible for community service providers to enter the jail in their efforts to maximize continuity of care. Their wait should be reduced to a minimum. (Sometimes it helps for them to make appointments.) And, to the extent consistent with effective security, the search procedure should be streamlined. In addition, service providers inside the jail and in the community should be encouraged to maintain phone contact with each other and the inmate, and the process should be streamlined by providing phone numbers to each for direct access.

11. Assignment of the responsibility as the treating agency must be made cooperatively and agreed upon by the inmate, the jail providers and the community agency accepting care.

12. The inmate prior to release should know a person from the outpatient treatment team/agency that accepts responsibility for community-based treatment and care, preferably via face to face contact. Ideally, caseworkers from the releasing facility would accompany the individual to housing or shelter and do assertive follow-up to insure continuity of care. Alternatively, community mental health, probation, the courts and the jail could establish a jointly funded team of case workers to carry out this transitional service.

13. Prescriptions or packaged medications should be provided for an adequate period of time (this depends on where and when the follow-up is scheduled.) Prescriptions can be provided in addition to medications. In addition, a complete summary of medications should be faxed to the outside provider prior to or close to the time of release. In any case, a plan must be in place prior to the individual's release that will provide a continuous supply of prescribed medications.

14. Responsibility to assume care of the individual between the time of release and the first outpatient appointment must be explicit and clearly communicated to the individual, to the family, and to both the releasing facility and the community agency. This responsibility should include ensuring that:

• the individual knows where, when, and with whom the first visit is scheduled to occur;

• the individual has adequate supply of medications to last until the first scheduled visit;

• the individual knows whom to contact if there is a problem with the prescribed medication and/or the pharmacist has a question about the prescription;

• the individual knows whom to contact if there are problems (medical or social), between discharge and their first scheduled outpatient appointment;

• the individual knows whom to call if it is necessary to change the scheduled appointment because of problems with transportation, day care, or work schedule.

15. A plan for transportation that will allow the individual to get to the scheduled appointment should be in place prior to release from the jail.

16. A plan for child care (if needed) that will allow the individual to keep the scheduled appointment should be in place prior to release.

17. A mechanism to track individuals who do not keep the first scheduled appointment should be in place (i.e., responsibility needs to be assigned to a person or agency such as the discharging facility, outpatient treatment agency, or managed care/case manager entity). The reason should be determined, and the appointment should either be rescheduled or the plan for follow-up should be renegotiated.

18. The release treatment plan must be carefully documented in the chart of the jail mental health services as well as the chart at the community mental health agency. For example, there should be documentation of the site of the mental health referral and time of the first appointment; precisely where the person will live and with whom after leaving the jail; involvement of the family in post-release planning or at least that a real effort has been made to include them; that direct or telephone contacts have been made with follow-up personnel; and that the "discharge summary" has been forwarded by the day of release.

19. A mechanism for rigorous Quality Assurance must be established. The jail and community providers should collaborate in establishing standards for post-release treatment planning, documentation and a mechanism to monitor implementation of the plan. For example, merely filling out a form titled "post-release plan" and putting one in each patient's file is not enough to demonstrate adequate post-release planning. A joint committee of representative jail providers and community mental health providers should meet regularly to monitor the process and establish appropriate consequences for staff whose work does not meet the standards established by the committee. In addition, when direct services are provided through a contract, standards for the development and implementation of post-release plans must be part of contract management, with penalties for poor performance.

20. An oversight group with appropriate judicial, law enforcement, social services and behavioral provider representation should be established to monitor the implementation of above recommendations.