The Criminogenic Risk and Behavioral Health Needs framework introduced state leaders and policymakers to the concept of prioritizing supervision and treatment resources for people based on their criminogenic risk and needs, as well as their behavioral health needs. Since then, the framework has been used as a foundational tool by federal grantees of the Second Chance Act (SCA) and the Justice and Mental Health Collaboration Program (JMHCP).

But many programs still struggle to develop and implement case plans that assist their participants in reducing their risk for recidivating and advancing their goals for recovery even though criminal justice and behavioral health professionals now have the tools to identify high-risk and high-needs people in the criminal justice system. However, these professionals can use the following web-based tool and resources to better integrate critical behavioral health and criminogenic risk and needs information into comprehensive case plans that actively engage the participant and reflect a balanced and collaborative partnership between criminal justice, behavioral health, and social service systems.


What are Collaborative Comprehensive Case Plans?

Case plans are both collaborative and comprehensive when the agencies involved in the participant’s case planning team and in the recovery processes work together with the participant (and the people in his or her support system) throughout the case planning process; and when the case plan includes information from behavioral health, criminogenic risk, and psychosocial assessments in a way that does not value results from one assessment over another. Below are three examples of the type of collaborative comprehensive case plans that criminal justice and behavioral health professionals can participate in and develop. Each example is centered around a leading agency (a lead case planner) that oversees the case planning process and engages the appropriate people in the partnering agencies, the participant, and the people in the participant’s support system. Click on each lead case planner for more information.


How are Collaborative Comprehensive Case Plans Implemented?

To develop and maintain Collaborative Comprehensive Case Plans (CC Case Plans) that reflect the partnership necessary to help each participant succeed, criminal justice and behavioral health professionals must include and incorporate the following 10 priorities and components. Each priority and component below also includes related tools and resources for further information, when applicable.


To develop CC Case Plans, lead case planners must identify the appropriate people from the agencies who will comprise the case management team for participants. The people on the case management teams should include representatives from criminal justice, behavioral health, and social service agencies to ensure that participants’ criminogenic risk and needs and behavioral health needs are addressed in a balanced manner.

Once the CC Case Plan has been established, the interagency collaboration should continue throughout the case management process. Information-sharing should occur frequently among the partnering agencies to ensure that assessment results and other important information about the participant is accurate and up to date. Written information-sharing protocols or policies should be developed that outline which information is shared by each agency and which agency receives that information.

Franklin County, Massachusetts

The Franklin County Sheriff’s Office did not try to start from scratch when identifying the appropriate partnering agencies for their reentry program. Instead, the sheriff looked to many of the agencies his staff had already collaborated with successfully and identified which agencies would best contribute to reentry planning and would also be most willing to help his staff manage participants’ case plans. Once those agencies were identified, he enlisted the help of local experts in criminal justice and behavioral health to make sure the program would adequately address participants’ criminogenic risk and needs and behavioral health needs.


  1. HIPAA privacy Rules and Sharing Information Related to Mental Health
  2. The Importance of Data and Information in Achieving Successful Criminal Justice Outcomes
  3. Information-Sharing in Criminal Justice-Mental Health Collaborations

To help participants reduce their risk of recidivating and advance their goals for recovery, all members of the case management team should be trained on the Risk-Need-Responsivity model and behavioral health recovery principles, and should learn how to use that information to develop participants’ case plans. Partnering agencies should use cross-training opportunities to help staff bridge any knowledge gaps and maximize the impact of training.

Marion County (Oregon) Reentry Initiative (MCRI)

Bridgeway Recovery Services, the behavioral health care provider for MCRI, offers and facilitates trainings on behavioral health and other relevant topics that their staff and officers and staff at the Marion County Sheriff’s Department can attend. This opportunity for cross training helps the sheriff’s department maximize its budget, but also allows the staff at both agencies to interact with and learn from each other.


Agencies should use validated criminogenic risk, substance use disorder, and mental illness screenings and assessments (see below for examples) to choose which participants are placed in reentry and diversion programs and to help them develop these participants’ case plans. Once the appropriate people in the partnering agencies have participants’ assessment results, they should incorporate this information into their case plans, and the results should inform the priorities of the case plan. Staff from the lead case planning agency who work directly with participants should continue to monitor these participants for the duration of the program so they can make adjustments to the case plan based on participants’ progress and status changes.


  1. Mental Health Screens for Corrections
  2. On the Over-Valuation of Risk for People with Mental Illnesses
  3. Risk Assessment Instruments Validated and Implemented in Correctional Settings in the United States
  4. Risk Needs Assessment 101: Science Reveals New Tools to Manage Offenders
  5. Screening and Assessment of Co-occurring Disorders in the Justice System
  6. Three Things You Can Do to Prevent Bias in Risk Assessment

Because multiple people and agencies will be involved in managing participants’ case plans, case conferences can help the people on the participants’ case management teams identify the available services to address their criminogenic, behavioral health, and psychosocial needs and prioritize those needs that are most critical to participants’ reentry success. Lead case planners should regularly have case conferences with participants and their case management teams to discuss any changes in participants’ needs or goals that might require adjustments to their reentry or diversion programming. To ensure these case conferences occur regularly and are most useful to participants, lead case planners should develop case conference procedures for each participant during the early stages of planning and make sure those mutually agreed-upon procedures are carried out in the case planning process. These procedures should encompass the manner in which the case conferences will be conducted,  how often they will be conducted, and what information each partner is expected to bring to the case conferences.


  1. Developing a Mental Health Court: An Interdisciplinary Curriculum (module 6: Case Planning)
  2. Engaging in Collaborative Partnerships to Support Reentry
  3. Engaging Stakeholders in Your Project

Lead case planners must ensure that participants and the people in their support system are actively involved in the development of their case plans. When participants are activity engaged, they are more likely to feel a sense of ownership over their programming and are more invested in their own recovery. When participants are included in the case planning process early on, lead case planners can also better incorporate the five remaining components into their case plans and help keep them fully engaged in the reentry or diversion programming.

Peer Mentors

Some lead case planners use peer mentors to help keep participants actively involved in their reentry programming. Bridgeway Recovery Services uses peer mentors to conduct weekly mentoring groups with participants while they are still incarcerated. After participants are released from prison, the peer mentors also spend the first day of release with participants to help connect them to resources (i.e., linkages to affordable housing options, referrals to medical care, and assistance in getting their government-issued identification reinstated).


  1. Enhancing Motivation for Change in Substance Abuse Treatment: Treatment Improvement Protocol (TIP) Series 35
  2. Motivational Interviewing in Corrections: A Comprehensive Guide to Implementing MI in Corrections
  3. Using a Systems Approach to Increase Client Engagement and Retention in the Community

Most participants will have multiple needs to address in their reentry or diversion programming, so lead case planners should prioritize addressing those needs that help decrease participants’ risk of recidivism, improve their health, and ensure public safety. Lead case planners can use participants’ criminogenic and behavioral health assessment results, as well as psychosocial information (i.e., information on their mental health and social well-being including housing status, employment and education history, and health insurance) to determine which needs should be prioritized and have a greater chance of being addressed through targeted interventions.

Lead case planners should help participants develop goals for their case plans that are based on these identified needs. Participants are more likely to succeed when their own goals are directly related to these needs.


  1. A Best Practice Approach to Community Reentry from Jails for Inmates with Co-occurring Disorders: The APIC Model
  2. Adults with Behavioral Health Needs under Correctional Supervision: A Shared Framework for Reducing Recidivism and Promoting Recovery
  3. A Checklist for Implementing Evidence-Based Practices and Programs (EBPs) for Justice-Involved Adults with Behavioral Health Disorders
  4. Guidelines for the Successful Transition of People with Behavioral Health Disorders from Jail and Prison
  5. Risk-Need-Responsivity Model for Offender Assessment and Rehabilitation

To incorporate responsivity principles into case plans, criminal justice and behavioral health professionals must adapt services and treatment to address each person’s unique characteristics and barriers to learning. Lead case planners should use the results from criminogenic, behavioral health, and psychosocial assessments to determine which tailored interventions can help participants based on these individual characteristics and how those characteristics can impact the effectiveness of participants’ treatment. Lead case planners should include participants’ general and specific responsivity considerations in the case plan and adapt treatment to reflect their individual limits and barriers. For general responsivity, social learning and cognitive behavioral interventions (such as Interactive Journaling or Moral Reconation Therapy) are used to address participants’ dynamic risk factors (as illustrated in the video above). For specific responsivity, lead case planners consider participants’ culture, motivations, strengths, gender, and learning styles when developing service, supervision, and treatment approaches.


Lead case planners should ask partner agencies for any legal information (such as court dates and conditions of supervision) that might impact participants’ supervision plans, conditions of release, court participation requirements, treatment approaches, interventions, or access to housing, employment, or other programs. This information should be included in participants’ case plans and shared with the appropriate people in the participants’ case management team so they can support participants in activities such as appearing in court when required, attending community supervision appointments, or finding affordable housing post incarceration.


One effective way to keep participants engaged in their reentry or diversion programming is to identify personal strengths, such as employment experience or family support, that can aid in their success. Lead case planners should account for these personal strengths (also known as protective factors) when developing case plans and ensure that participants are engaged in evidence-based programming that can build on those strengths and reduce their chances of recidivating.

San Joaquin County, California

Probation officers in San Joaquin County’s Probation Department (the lead case planner for their collaboration) develop participants’ reentry plans in coordination with that participant and his or her family, clinician, and case manager. By engaging participants and the people in their support systems early on, probation officers can get participants to think about their own personal strengths that will help them succeed in achieving their reentry and recovery goals.


Women often have different behavioral health needs and responsivity factors than men, so lead case planners or one of their partner agencies should utilize gender-responsive approaches to help women develop goals related to their specific needs. These approaches can help agencies ensure that risk and behavioral health screening and assessments tools, case management processes, and programming are effective for women in the justice system. Some examples of considerations that can negatively impact women’s reentry success are child custody issues, financial challenges, and past trauma. Women are more likely to be engaged in their programming when lead case planners incorporate gender-responsive services into case plans and ensure those results are reflected in their reentry or diversion programming.


  1. Addressing the Needs of Women and Girls: Developing Core Competencies for Mental Health and Substance Abuse Service Professionals
  2. Gender-Responsive Policy and Practice Assessment (GRPPA)
  3. Guidance to States: Treatment Standards for Women with Substance Use Disorders
  4. Reentry Considerations for Justice Involved Women
  5. Ten Truths That Matter When working with Justice Involved Women
  6. Women Offender Case Management Model

Other Considerations

What Other Resources Should Be Considered?

The resources below can further guide lead case planners from behavioral health treatment providers, community supervision agencies, and correctional agencies in their case planning processes. These resources take into account the issues that criminal justice and behavioral health professionals face across the country and offer ways to ensure all participants’ needs are fully met and their reentry or diversion is successful.

Mental Health Courts


Opioid Addiction


This project was supported by Grant No. 2016-MU-BX-K011 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Department of Justice’s Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.

Key Staff

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Sarah Wurzburg
Program Director, Behavioral Health
Sarah Wurzburg oversees technical assistance focused on behavioral health, diversion, and reentry and serves as the lead for projects related to substance use, mental illnesses, and housing. She leads the work on the development of community responder programs, including a
toolkit that supports sites in development of non-police responses to people in crisis. Previously, Sarah was a research analyst at the National Association of State Alcohol and Drug Abuse Directors, Inc., where she was the team lead for Youth and Women’s Services and was the primary author of research reports on youth substance use disorder treatment, driving under the influence, and Medicaid. Sarah has also worked as a juvenile court advocate and in community substance use disorder prevention. She received her BA from DePauw University in English (writing) and her MA in social services administration with a focus on policy analysis from the University of Chicago.
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