In order to achieve successful re-entry into the community, individuals with ongoing treatment needs must be connected to a community-based provider prior to their release from prison and jail. The effort to effectively coordinate a person's treatment in a correctional institution with their treatment in the community depends in part on the availability and proximity of community-based health care and substance abuse treatment providers. Partnerships between corrections and community providers may therefore run the gamut from programs in which patients see the same primary providers or substance abuse professionals during and after incarceration, to those in which people develop relationships with community providers only during the final months of their incarceration, to those in which inmates simply learn about a community provider in a pre-release referral. (See Policy Statement 10, Physical Health Care and Policy Statement 12, Substance Abuse Treatment for more on engaging community-based providers in treatment of people during their incarceration.) Communities are also developing innovative ways to connect their mental health, substance abuse, and criminal justice systems in an effort to intervene, divert, and treat people with co‑occurring disorders. (See Policy Statement 11, Mental Health Care, for a more extensive discussion of treatment for co-occurring mental health and substance abuse disorders.)

Corrections officials who allow treatment providers from the community to establish a relationship with the individual while he or she is still incarcerated ensure the greatest continuity of care. For this reason, corrections officials in facilities that have policies preventing external service providers from even visiting the facility should consider eliminating such bans. ^[1]   Many correctional facilities already provide medical care to inmates by contracting with private providers; contracting with those who also provide community-based health services can both improve continuity of care and increase capacity in communities to which people return from prison or jail. Corrections should encourage community-based organizations to establish a pre-release relationship with inmates either by providing direct services to the inmate during his incarceration, or by offering more general pre-release planning.

Example: Project Bridge, Miriam Hospital (RI)

Project Bridge provides a variety of services for HIV-infected inmates within the Rhode Island correctional system. First, Brown University or Miriam Hospital - based infectious disease specialists treat HIV-infected inmates within the correctional system. In addition, approximately 60 days prior to a person's release, a two-person team from Project Bridge (an outreach worker and a social worker) approaches potential participants to develop a treatment plan. Upon release, project participants usually see the same medical providers they saw while they were in prison. Moreover, the team members provide reminders and transportation assistance for medical appointments, facilitate communication with hospital staff, and help participants obtain other social services, including substance abuse treatment.

Example: Project Success (FL)

Project Success is an 18-month substance abuse treatment program for adult females that works with women both during and after their incarceration. Program staff visit the county jail monthly to inform women about Project Success. Women who are eligible to participate, have enough time remaining in their sentences to complete the six-month residential component of the program, and are interested in participating are admitted to the program. When the women return to the community, they enter a 12-month aftercare phase. During that phase, Project Success provides the women with case management services, including housing placements.

Even if the community provider does not actually work with the individual prior to his or her release, institutional health and substance abuse professionals should at least provide each outgoing prisoner with a referral to a community-based provider or program qualified to continue his or her treatment.

Example: Snohomish County Human Services, Division of Alcohol and Other Drugs (WA)

The Snohomish County Division of Alcohol and Other Drugs operates a variety of outpatient treatment programs to serve low-income county residents. One of the six treatment providers that work with the Division specializes in treating co-occurring substance abuse disorders in people with a diagnosed mental illness. At the request of the Department of Corrections, case managers from that provider will conduct assessments in the local prison or jail, so that individuals with co-occurring disorders can obtain appropriate treatment upon their release.

To refer a prisoner to a community health care provider effectively, prison service providers should consider the individual's summary health record and/or his or her transitional plan to determine ongoing treatment needs. Further, transition planners (perhaps in conjunction with public health officers or representatives from community-based organizations) should make the outreach and research efforts necessary to familiarize themselves with the services available in their particular community. For instance, in New York, a person with HIV/AIDS may receive better care at a designated HIV/AIDS center where the providers have specialized experience working with that disease. In another city, corrections officials, working through state agencies or hospital associations, may find that the best care comes from well-established community centers. Still elsewhere, a strong private hospital may be the best option for referrals. Ideally, this learning and outreach process will result in not only increased information for referrals, but also better relationships and increased partnerships between corrections and the community.

Transition planners should coordinate carefully with whichever community-based providers they determine to be appropriate, as well as with community corrections officers, to ensure that people leaving prison and jail have a safety plan to immediately obtain needed services upon release. Ideally, people who are leaving prison or jail will be able to continue their treatment with a program that shares the same or similar philosophy of care and treatment modalities as their institutional drug program. This explicit form of continuity of care is most efficient because it not only increases the duration of treatment but also builds on treatment methods that are already familiar to the prisoner, rather than introducing a whole new set of interventions.

Corrections administrators need to provide as much advance notice as possible about the inmate's projected release date to the correctional health care providers or transition planners who are actually responsible for linking the inmate with community services. Two to three months' notice may be sufficient to make all the necessary preparations, but the more advance planning there is, the more careful and thorough the transfer can be. Corrections treatment providers can smooth the transition and maximize the likelihood of patient cooperation with treatment if they also promptly advise the community provider of the release date and send along the inmate's summary health record and any other specific referral information. Even such basic steps could enhance the continuity of care for many inmates re-entering the community.

Example: Aftercare Planning in Health Services, North Carolina Department of Corrections Division of Prisons

Aftercare Planning in Health Services seeks to ensure continuity of care for every inmate identified as mentally ill, developmentally disabled, and/or medically needy. Approximately six months prior to the inmate's release, the inmate and social worker (along with other members of the institutional treatment team) complete an aftercare plan to coordinate the inmate's mental health, medical care, and other social service needs postrelease. The program works with a host of community-based partners, including Duke University Medical Center, East Carolina School of Medicine, and the University of North Carolina hospital system, the Veterans Administration, community faith-based organizations, Alcoholics Anonymous, and Narcotics Anonymous.

Individuals who are in and out of jail in a period far shorter than two to three months would also benefit from well-established relationships with community providers. If nothing else, they can be directed to a community provider and given a copy of any initial assessment documentation. (See Policy Statement 10, Physical Health Care, for more on medical evaluations for short-term inmates.) People who have been in treatment for substance abuse issues during their incarceration should receive written and oral information about area walk-in substance abuse programs upon their release. At a minimum, transition planners should help any person leaving prison or jail who has substance abuse issues identify meetings of peer support groups (such as Alcoholics or Narcotics Anonymous) that are located near to where he or she will live and/or work. Probationers or parolees should then be able to provide proof of attendance to their community supervision officers upon their first meeting. As appropriate, referrals should be made for medical, dental, mental health, substance abuse, and/or cognitive/behavioral programs. Indeed, no inmate should leave the facility without a set appointment or appointments with a community-based provider or providers. Referring prisoners to community providers need not be a huge investment on the part of a department of corrections, particularly given that some materials already exist which identify low-income providers. In addition to public hospitals and clinics affiliated with state or local departments of health and mental health, resources such as the National Free Clinic Directory (www.medkind.com/scripts/modules/module6/a3.idc) can provide listings of free health care clinics nationwide.