Lead Case Planner: Behavioral Health Treatment Provider

The agency that takes the lead in case planning and case management, referred to here as lead case planner, can vary based on several factors, such as available funding, pre-existing relationships among agencies in the jurisdiction, and the needs and goals of the participant. The most common lead case planners are: community-based behavioral health treatment providers; community supervision agencies, such as probation or parole; and correctional agencies, such as local jails or state prisons.

The following graphic shows an example centered around the lead case planner that oversees the case planning process and engages the appropriate people from each partnering agency, the participant, and people in the participant’s support system (the case management team) during the diversion or reentry process. When a community-based behavioral health treatment provider is the lead case planner, the staff member who creates case, service, or treatment plans and conducts case management for program participants may be a case manager, therapist, social worker, or team leader. Click on the categories in the circle below to view examples of the kinds of information partners in the case management team usually keep in their records about participants and what information the lead case planner should share with these partners.

For more information, view this webinar, which provides additional information and examples on how a community-based behavioral health treatment provider can facilitate interagency collaboration and information sharing, staff training, and screening and assessment.

Case Management Team Roles

Participant

Lead case planner sends the following information:

All of the information that is documented in the case plan

Lead case planner receives the following information:

Personal strengths
Historical/background information
Any changes in residence and other personal information related to responsivity issues and service provision
Personal goals and any barriers that might affect achievement of those goals
Requests for help and assistance
Recovery goals and any relapse prevention work

Participant Support System

(including family, friends, and other sources of support)

Lead case planner sends the following information:

Participant’s goals
Limitations or rules that the participant must follow
Who to contact if there are any problems or if they need assistance

Lead case planner receives the following information:

Historical/background information
Current and updated participant strengths, challenges, progress towards goal achievement, and any behavioral changes
Any changes in residence and other personal information related to responsivity issues and service provision
Shared goals with family/significant people

Children’s Service Agencies

(including welfare agencies, schools, day care providers, pediatric health care providers)

Lead case planner sends the following information:

If participant does not have full custody of child or children, the following information may need to be shared with permission:
- Treatment attendance and drug testing results
- Compliance with court conditions
- Employment or education status
- Housing status
- Child-rearing responsibilities such as school or day care pick-up and drop-off times and any appointment times that could interfere with reporting times
- A designated point of contact for assistance with children in case of emergency
- Child support requirements

If participant has custody of children, the following information may be shared:
- Appointment times for substance use and mental illness treatment, community supervision, and any other appointment times that may conflict with the participant’s own requirements in reentry or diversion

Lead case planner receives the following information:

If participant does not have full custody of child or children, the following information may need to be shared with permission:
- Updates on legal proceedings for child custody
- Any changes in requirements or status for regaining custody
- Child visitation schedules
- Child support requirements

If participant has custody of children, the following information may be shared:
- Scheduling information as necessary so that the participant’s reentry or diversion activity schedule does not conflict with parenting obligations, i.e., regular school pickup and drop-off times

Medical Provider

Lead case planner sends the following information:

Medical information (if necessary) that would ensure completion of procedures and treatment (with participant consent)
Health care insurance information (if available)
List of current medications, prescribed by BH providers and other medical provider(s)

Lead case planner receives the following information:

Medical information that pertains to the participant’s capacity to comply with conditions of release/diversion or community supervision (i.e. cognitive/neurological impairment that would prevent successful completion of a CBT intervention)
Insurance
Information/records pertaining to Supplemental Security Income or Social Security Disability Insurance (SSI/SSDI) applications and appeals
List of any currently prescribed medications
Information pertaining to follow up medical procedures and other ongoing treatment

Substance use DIsorder Treatment Provider

Lead case planner sends the following information:

Conditions of release/diversion and community supervision, where applicable
Triggers for relapse
Substance use history, if available, including patterns of usage connected to the participant’s inclusion in justice system
Mental health and primary care provider information for coordination
List of current medications, prescribed by mental health treatment provider and medical provider(s)

Lead case planner receives the following information:

Compliance with substance use disorder treatment conditions of release/diversion and community supervision
Treatment updates and progress that relate to the person’s status on community supervision or in diversion programming, including relapses and challenges within the recovery process
List of any currently prescribed medications
If the provider is licensed to deliver treatment for co-occurring substance use disorders and mental illness, then intra-agency coordination should be the focus
If there are multiple providers delivering treatment for substance use and mental illness, then coordination between agencies to share information should be the focus

Mental Illness Treatment Provider

Lead case planner sends the following information:

Conditions of release/diversion and community supervision, where applicable
Any destabilizing factors as they apply specifically to mental health status
List of current medications, prescribed by addiction psychiatrist and medical provider(s)
All other information in the plan that would assist with the provision of treatment, in coordination with the substance use treatment provider (when services are not integrated), and with the provision of any case management or other support services (if also provided by the same agency)

Lead case planner receives the following information:

Compliance with mental health treatment conditions of release/diversion and community supervision, when applicable
Any information that pertains to the participant’s survival (e.g., suicidal ideation) and status on community supervision or in diversion programming
List of any currently prescribed medications
If the provider is licensed to deliver treatment for co-occurring substance use disorders and mental illness, then intra-agency coordination should be the focus
If there are multiple providers delivering treatment for substance use and mental illness, then coordination between agencies to share information should be the focus

Courts

Lead case planner sends the following information:

Updates on court-ordered conditions, including treatment, employment, and housing
Types and availability of services in the community and a participant’s eligibility for these services
Screening and assessments, including criminogenic risk assessment information
Results from drug testing
Documentation detailing valid reasons why a court appearance is missed

Lead case planner receives the following information:

Court-ordered conditions
The disposition of the participant’s case
Screening and assessment results
Participant’s legal history
Pre-sentence investigation reports when community supervision is the primary plan holder

Community Supervision

Lead case planner sends the following information:

Criminogenic risk factors
Participant’s community supervision history and current pertinent details that might affect community supervision status and any diversion programming, if applicable
Housing location and contact information
List of participant’s current medications

Lead case planner receives the following information:

Conditions of community supervision
When the lead case planner is the behavioral health treatment provider, the community supervisor will need to provide the rules and conditions set by community supervision and all the criteria that is covered by the larger plan (except for record of arrests and prosecution, or rap sheets)

Correctional Facility

Lead case planner sends the following information:

Screening and assessments
Details on services that are available in the community and availability of treatment slots or housing placements
Participant’s enrollment status for public benefits
Participant’s prior treatment history

Lead case planner receives the following information:

Details on how individuals are referred and enrolled into in-custody programming
Screening and assessments, including substance use, mental illness, and criminogenic risk
Discharge plans, including services that were provided while in custody
Participant’s enrollment in health insurance and other public benefits
Medical status, including medications prescribed in custody
Participant’s legal status and history, including disciplinary history while in custody
Release date

Vocational, employment, and education support services providers

Lead case planner sends the following information:

Any individual factors that could impede the participant’s ability to work or attend school
Interventions the participant is receiving that are needed to support him or her in vocational training or in education
Participant strengths
Long term goals related to career or education

Lead case planner receives the following information:

Progress reports and updates on vocational and educational-related goals and behaviors
Attendance records (if required by the court or community supervisor)

Specialized Housing Provider

Lead case planner sends the following information:

Specific supports, if any, the participant needs in order to succeed in certain housing situations
Legal circumstances that can impact housing
The participant’s income
Details concerning whether the community supervisor will need to check in on the participant at home and if so, how regularly
A list of the participant’s current medications

Lead case planner receives the following information:

Services provided
Housing rules
Updates on the participant’s progress while housed, and if there are any disciplinary issues or behavioral changes
Changes, if any, in skills and ability to function independently

Peer Support

Lead case planner sends the following information:

All information in the plan, so that the peer support specialist can fully understand goals, services, legal requirements/status, and recidivism risk

Lead case planner receives the following information:

Updates regarding compliance with conditions of release/diversion or community supervision, when required
Any information that pertains to the person’s status on community supervision or in diversion programming
Schedule of required appointments, court, and community supervision appearances
Needs related to application for public benefits and health insurance for assistance with follow up advocacy
Information about the participant’s prosocial activity interests

Profile

Bridgeway Recovery Services
with the Marion County Reentry Initiative (MCRI)
Marion County, Oregon

NOTABLE FEATURES

The Marion County Sheriff’s Department in Salem, Oregon was a Second Chance Act (SCA) Reentry Program for Adults with Co-occurring Substance Use and Mental Disorders grantee in Fiscal Year 2013
Jurisdiction geography: Urban; 336,316 residents
Size of correctional facilities and populations incarcerated: 450 men and women at Marion County Jail and 2,000 men at Oregon State Penitentiary

PROGRAM DESCRIPTION

Bridgeway Recovery Services is a community-based treatment provider that offers mental health, substance use disorder, and problem gambling treatment. Bridgeway also serves as the lead case planner for the Marion County Reentry Initiative (MCRI), which is a collaboration including the Marion County Sheriff’s Department, Marion County Community Corrections, Oregon Department of Corrections, and Bridgeway that seeks to reduce crime and recidivism by engaging partners from community corrections, education, law enforcement, health, and nonprofit agencies in efforts around case planning and reentry. As the lead case planner and behavioral health care provider, Bridgeway partners with the other agencies and departments to coordinate and provide services for people reentering the community in Marion County.

Marion County received funding through the Second Chance Act in FY2013 to form the MCRI Co-Occurring Disorders Project—also known as Link Up—which helps males with a medium to high risk of recidivism who are diagnosed with co-occurring mental and substance use disorders reenter the community successfully and/or stabilize their symptoms while on community supervision. Males in the program must be within six months of scheduled release from prison and are connected to health insurance, community-based treatment, job skills/readiness training, emergency assistance, information about affordable housing, peer mentors, and other critical services and organizations following their release. One key piece of the project’s success is the use of peer mentors, who are certified recovery mentors, in providing case management. The peer mentors meet with participants while they are incarcerated and conduct bi-weekly mentoring groups as well as one-on-one support. Peer mentors spend the first day of release with participants to connect them to resources.

When the SCA grant ended, Marion County sustained Link Up with funding from the Sheriff’s Department, and Bridgeway now operates six programs focused on reentry or diversion, with the help of its partners in the MCRI. These programs were made possible through years of relationship building among these agencies and other collaborators.

MCRI staff use the following instruments to screen and assess program participants:

The Level of Service/Case Management inventory (LS/CMI), provided by the Department of Corrections and the Sheriff’s Department
University of Rhode Island Change Inventory (URICA)
Life Events and Post-Traumatic Stress Disorder (PTSD) Checklists
Texas Christian University Drug Screen (TCUDS)
Texas Christian University Criminal Thinking Scales
Patient Health Questionnaire-9 (PHQ-9)
Generalized Anxiety Disorder Assessment (GAD-7)

Lead Case Planners and their partners were asked to provide information about how their programs implement some of the Collaborative Comprehensive Case Plan priorities. See below for more information about the Marion County Reentry Initiative’s efforts.

Interagency Collaboration and Information Sharing

While Marion County had years of relationship-building among their various agencies, the Sheriff’s Department determined that the best way to do this work would be to contract with Bridgeway to take the lead in coordinating case and treatment planning (with the Sheriff’s Department playing an oversight role). As the lead case planner in the MCRI, Bridgeway’s Director of Behavioral Health, Tina Bialas, and her staff spend a significant amount of time coordinating with their partners for the case planning process to make sure that all their activities are aligned in support of participants in their programs.

Another key aspect of what makes MCRI effective is the leadership buy-in from all the partnering agencies. Bridgeway’s CEO Tim Murphy and Commander Jeff Wood of the Marion County Sheriff’s Department collaborated on initiatives before the county received their SCA award, which showed the middle management and program line staff at each agency the value of collaboration and helped build the foundation for the collaboration.

Tip: Clinical agency staff should get to know their partners in the criminal justice system and their roles, and familiarize themselves with the processes at the correctional facility —Matt Meier, sergeant at Marion County Sheriff’s Department

Staff Training

Bridgeway’s corrections treatment team provides behavioral health treatment to participants who are reentering the community or being diverted from corrections institutions. One important component of building the team is staff selection, which begins before job candidates are hired. Through the interview process, Bridgeway staff can gauge a candidate’s interest in working with people who have been involved in the justice system and learn more about a candidate’s corrections experience, such as whether the candidate has worked in a correctional facility or has personal experience with incarceration. More than half the corrections treatment team has lived experience with the corrections system.

Bridgeway also prioritizes training staff from the moment they are hired, and is constantly working with the MCRI partners to help provide training so that staff can better incorporate criminogenic and behavioral health needs into participants’ case plans. Some trainings include ways to use the risk-need-responsivity (RNR) model to develop treatment for people convicted of sex offenses; training from the Oregon Department of Corrections on the LSCMI tool and the Women’s Risk and Need Assessment (WRNA); training on the Prison Rape Elimination Act (PREA); and training on trauma-informed care. In addition, Bridgeway has had its peer mentors trained in Effective Practices in Community Supervision (EPICS)—a model that was developed for community supervision officers—and has cross-trained community supervision agents on behavioral health.

Bridgeway is not the only MCRI partner to develop training protocols to help its staff in case planning, however. The Marion County Sheriff’s Department also trains its officers and other staff on principles around RNR and encourages these staff to attend Bridgeway trainings on behavioral health and other topics.

Screening and Assessment

The MCRI screening and assessment process involves multiple steps. For potential participants who are on community supervision, Bridgeway staff receive copies of the LSCMI assessments from the Marion County Sheriff’s Department. The Oregon Department of Corrections also provides quarterly lists of people incarcerated in their facilities who meet initial qualifiers for the in-reach component of the program. Bridgeway counselors then conduct a biopsychosocial assessment for substance use disorders and mental illnesses, and obtain demographic and other background information from potential participants once they can attend clinic-based services. After staff determine that the person meets eligibility criteria for Link Up, they incorporate results from all assessments into the person’s case plan. The LSCMI assessment scores in each domain (specific criminogenic risk factors such as antisocial peers or conflict in family or relationship circumstances) help Bridgeway staff determine which areas to focus on when creating participants’ case plans and the specific criminogenic needs to be targeted in programming.

After Bridgeway staff have developed a participant’s case plan, they coordinate with the participant’s certified recovery mentor and therapist, community supervision agent, sergeants at the Marion County Sheriff’s Department, and Bridgeway supervisors to identify the most appropriate interventions for addressing that person’s criminogenic risk and behavioral health. The corrections treatment team at Bridgeway runs 40 treatment groups per week, utilizing evidence-based treatment materials including Interactive Journaling. This wide selection of groups assures that participants can receive individualized treatment guided by what is clinically indicated in their assessments. Each participant works towards the goals they have outlined with their therapist in their case plans, which include measurable objectives that target criminogenic risk factors as well as common behavioral health concerns.