Intercept 4 – Reentry

Proper training to support individuals with mental health and substance use challenges is vital during the critical transition of reentering communities after incarceration.

SIM diagram

Intercept 4 – Reentry

Intercept 4 involves all services, care and planning involved in transitioning individuals from jail or prison back to the community. Reentry efforts and coordination should begin as early as possible in the individual’s stay, as increased planning and coordination has been shown to lead to better outcomes, more treatment adherence and less recidivism. It is critical at this stage that any planning be customized and workable for the individual’s specific needs, including but not limited to mental health/substance use treatment, health care, insurance/Medicaid and access to medication. There must be an increase in supports and careful planning at this intercept to reduce the likelihood of reengagement/continued engagement with the legal system.

Intercept 4 CCBHC Integration Opportunities

  • Transition planning by the jail or in-reach providers
  • Medication and prescription access upon release from jail or prison
  • Warm handoffs from corrections to providers increases engagement

More than two-thirds (70%) of CCBHCs coordinate with local jails to provide pre-release screening, referrals or other activities to ensure continuity of care upon individuals’ reentry to the community from jail. Through their partnerships with jails and prisons, CCBHCs support warm handoffs from correctional settings to community-based settings to reduce risks of harms, including overdose, suicide or other adverse events. CCBHCs have staff who can also work to enroll or re-enroll individuals into benefits like Medicaid to ensure their services are covered.

Intercept 4 Core Competencies

Collaboration and Teamwork
  • Adopt a single system-wide county definition of key terms consistently used by local behavioral health systems, jails, courts and community corrections, including but not limited to:
    1. Substance use disorders
    2. Serious mental illness
    3. Recidivism
  • Conduct a Sequential Intercept Model mapping workshop.
  • Identify service capacity/interventions/gaps.
  • Understand respective roles and responsibilities.
  • Obtain leadership commitment (criminal justice council or task force).
  • Develop collaborative criminal justice and behavioral task force if one does not already exist.
Workforce Development
  • Identify evidence-based interventions and best practices for improving the jail-to-treatment pipeline.
    1. Medication Assisted Treatment (Long Acting Injectables)
    2. Trauma Informed Care (TIC)
    3. Motivational Interviewing
    4. Cognitive Behavioral Therapy (CBT)
    5. Housing services
    6. Family support
    7. Vocational training
    8. Literacy training
    9. Employment assistance
    10. Peer Navigators/Recovery Coaches
  • Provide cross-systems training on:
    1. Substance Use Disorder and Medication Assisted Treatment (MAT)
    2. Implicit bias
    3. Data and evaluation
    4. Trauma-informed Care
    5. MHFA for public safety
    6. Motivational Interviewing
    7. Screening, Brief Intervention and Referral to Treatment (SBIRT)
    8. Peer Navigators/Recovery Coaches
    9. Integrated mental health treatment for co-occurring substance use disorders
Screening and Assessment
  • Assess the individual’s clinical and social needs and public safety risk.
  • Implement validated screening and assessment tools and an efficient screening and assessment process.
    1. Inclusive of social determinants screenings and assessments.
  • Utilize the Risk, Needs, Responsivity (RNR) Model and ensure alignment with behavioral health treatment approach.
    1. Criminogenic risk
    2. Substance use/misuse
    3. Mental illness
  • Share assessment information with partners to streamline workflow and coordinate care.
Care Planning and Care Coordination
  • Utilize the Assess, Plan, Identify and Coordinate (APIC) Model to coordinate reentry services.
  • Develop process for linking to services (warm handoffs, in-reach).
  • Plan for the treatment and services required to address the individual’s needs, both in custody and upon reentry.
    1. Inclusive of in-reach services related to Medicaid suspension/enrollment
  • Identify required community and correctional programs responsible for post-release services.
  • Coordinate the transition plan to ensure implementation and avoid gaps in care with community-based services.
    1. Guidelines for Successful Transition of People with Mental or Substance Use Disorders from Jail and Prison: Implementation Guide
    2. Data Collection Across the Sequential Intercept Model (SIM): Essential Measures
Cultural Humility
  • Apply and address across remaining categories once competent in these principles:
    1. Implement/enhance anti-racist training and education.
    2. Adapt services to language, gender and pronoun preferences and cultural norms of population served.
  • Develop task force that is inclusive of individuals with lived experience to spearhead the implementation/assessment of anti-racist policies and procedures, training and education.
Racial and Ethnic Disparities
  • Identify and address racial disparities within criminal justice system involvement and in health care access and quality for populations served.
  • Develop task force for racial and ethnic disparities to help achieve the following goals:
    1. Set qualitative process and outcome goals for racial and ethnic disparity reduction.
    2. Set a numerical target for reducing justice system involvement and/or improving outcomes for Black, Indigenous and people of color (BIPOC).
    3. Set a numerical target for reducing the relative likelihood of justice system involvement for BIPOC compared to White adults.
Evaluation and Quality Improvement
  • Develop a city/county-level training plan that includes quality assurance to ensure fidelity.
  • Develop a city/county-level plan for information/data sharing.
  • Data Collection Across the Sequential Intercept Model (SIM): Essential Measures
  • Agree on how to measure recidivism and other health outcomes. For example:
    1. Recidivism outcomes:
      • Reduction in police contact, arrest and reincarceration.
    2. Health outcomes:
      • Reduction in wait time for accessing services.
      • Track no-shows.
      • Track medication refills.
      • Rate of homelessness upon release/access to housing.
      • Reduction in hospitalization/ER rates.
      • Increase access to care coordination.
      • Reduction in wait time for Medicaid reinstatement.
Funding and Sustainability
  • Prioritize policy, practice and funding improvements.
  • Understand Medicaid/SSA coverage.
  • Routinely communicate with the people responsible for the county budget.
  • Utilize data to justify funding.
  • Explore federal funding opportunities.

National Council Resources

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