Lead Case Planner: Correctional Agency
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 correctional agency is the lead case planner, the staff person who creates case plans—also known as reentry, service, or discharge plans—and conducts case management may be a corrections officer, correctional health worker, correctional counselor, discharge planner, or reentry case worker. The staff member assigned to this role may vary depending on the jurisdiction and the size of the agency. 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 correctional agency 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)
- Healthcare 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 assessments 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 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)
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
Franklin County Sheriff’s Office
Franklin County, Massachusetts
NOTABLE FEATURES
- The Franklin County Sheriff’s Office in Greenfield, Massachusetts was a Second Chance Act Reentry Program for Adults with Co-occurring Substance Use and Mental Disorders grantee in Fiscal Year 2013
- Jurisdiction geography: Rural; 71,372 residents
- Size of correctional facilities and populations incarcerated: 250 men
PROGRAM DESCRIPTION
Under the leadership of Sheriff Christopher J. Donelan, the Franklin County Sheriff’s Office (FCSO) implemented a trauma-informed, integrated substance use and mental disorders treatment program in 2014 for approximately 120 men who were sentenced and incarcerated. Most of these men were assessed as having high- to very high-criminogenic risk. Since then, the FCSO expanded program eligibility to pretrial detainees and now includes approximately 175 men. Although the FCSO only incarcerates men (women are housed in a regional facility in a nearby county), case management support is available through FCSO to both male and female participants post release. FCSO offers participants evidence-based interventions, including Integrated Dual Disorder Treatment (IDDT) case management for people while incarcerated and post release, Thinking for a Change (T4C), Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), Stages of Change and Motivational Interviewing, Seeking Safety, and Nurturing Parenting. Program participants also receive group therapy, peer mentoring, case management, education, and vocational services prior to release and are also connected to supported or affordable housing. As participants move through phases of the program they are transitioned to different sections of the jail with lower security levels until they are released.
FCSO staff use the following instruments to screen and assess program participants:
- PROXY static risk assessment
- Level of Service/Risk-Need-Responsivity (LS/RNR)
- Clinical diagnostic assessment
- Adverse Childhood Experience (ACE) scale
- Brief Situational Confidence Questionnaire (BSCQ)
- Comprehensive ACT Assessment (CompACT)
- Toronto Alexithymia Scale (TAS-20)
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 efforts in Franklin County, MA.
INTERAGENCY COLLABORATION AND INFORMATION SHARING
Before FCSO received its Second Chance Act (SCA) award to fund its reentry program, it was selected as a site for the Transition from Jail to Community initiative, a project between the National Institute of Corrections and the Urban Institute that provided technical assistance to test a model for improving long-term reintegration outcomes for people returning from incarceration. As part of the initiative, Sheriff Donelan reached out to social service agencies and legal partners to form a leadership committee. The FCSO also tapped into existing county coalitions to support its efforts to improve reentry and help them design their treatment program so it would be aligned with the needs of their population. Ed Hayes, assistant superintendent of human services, notes that the county’s pre-existing culture of agency collaboration (because the county is rural with limited resources) helped to form the initiative, and multiple community and government partners were willing to assist the FCSO, especially after they began to see the effects of opioid misuse and opioid use disorders on the county.
Sheriff Donelan also realized opportunities for intra-agency collaboration among the staff at the jail to help make the treatment program successful. While there was some initial resistance from security and treatment staff at FCSO to reentry programming for people who have co-occurring disorders, FCSO began hiring for correctional officer positions who would also serve as correctional case workers to specifically partner with treatment staff and co-lead groups. The hiring protocol at the FCSO also changed to focus on the sheriff’s reentry priorities and to seek out applicants with human services background to be corrections officers. Additional case workers were also hired to provide intensive post-release support, including wraparound services, such as transportation assistance, recovery coaching, and systems navigation. This case management continues post release as long as participants are fully engaged in it.
The information sharing process occurs internally between the various divisions at the FCSO and externally with partner agencies and family members of participants. Internally, case conferences occur weekly and include staff from the education, clinical, medical, security, and reentry teams. Participants with cases of concern are discussed and relevant community-based agencies are contacted according to those discussed needs (such as referrals to the Department of Mental Health to qualify for additional resources). This participant information is also stored digitally within FCSO’s case management software, making information sharing simple and direct. Externally, FCSO’s information-sharing process begins during participants’ initial intake and continues as reentry case plans are developed in consultation with partnering agencies and the people in the participant’s support system. When it is deemed appropriate and helpful to ensuring continuity of care, FCSO’s information-sharing protocols allow for behavioral health, medical, and other case management data to be shared with relevant partners as well.
STAFF TRAINING
The FCSO reentry program is based on two core frameworks: 1) risk-need-responsivity (RNR) and 2) a behaviorist approach to trauma-informed, integrated mental illness and substance use treatment focused on learning new behaviors to address co-occurring disorders and criminogenic risk. FCSO case workers and their licensed behavioral health care partners complete cross-training on security and core trauma-informed treatment principles, and on evidence-based interventions (see above). Additionally, all new uniformed officers participate in training on RNR, behaviorism, and substance use disorder principles during their cadet academy, with refresher trainings offered annually.
All human service staff at FCSO receive an intensive two or three-day training in RNR and are certified to administer a criminogenic risk and need assessment. The human services team then applies lessons learned from these trainings to weekly reviews of participant cases. Monthly lectures are held to continue to develop the staff skill sets around these modalities and other topics such as staff resiliency and secondary trauma.
While the SCA grant provided some funding for these trainings, Sheriff Donelan also prioritized training in the agency’s budget and directed some general appropriations to fund the trainings. The FCSO leadership team sought external partners to deliver trainings when possible, instead of trying to plan and deliver all trainings in-house because partners in the community often have the knowledge and the ability to cross-train in different areas.
SCREENING AND ASSESSMENT
The FCSO uses screening and assessments to help develop case plans for reentry program participants. Participants are assessed for criminogenic risk using the Level of Service/Risk Need Responsivity (LS/RNR), and a licensed behavioral health specialist conducts a clinical biopsychosocial assessment for both mental illness and substance use disorders. The combination of these assessments along with additional screens and assessments (see above) helps the team focus the interventions on criminogenic and behavioral health needs and to identify each participant’s goals and values in life. Together these assessments inform participants’ treatment within the facility, which is then documented in their Individualized Service Plans (ISP). Depending upon participants’ level of risk and need, the ISP will include various levels of intervention, such as evidence-based treatments, vocational & educational programs, comprehensive reentry services, and post-release reentry supports.
A reentry case worker meets with program participants within the first few days of incarceration to conduct additional screening and case planning. Using a software application called iCIM—which contains several domains such as mental health, recovery support, and housing—the case worker determines where participants need the most support to succeed and includes that information in their reentry case plan. That plan is reviewed by the case management team regularly and updated as participants’ behaviors and/or circumstances change. The case management team conducts formal reviews of these plans every 60 days.
Prior to their release from the jail, participants meet with their case worker, post-release case worker, a medical practitioner, and key community partners such as a probation officer, recovery coach, or other agency representative to review any final details of the reentry case plan together (which is a continuation of their ISP). The medical practitioner will review any arrangements that are made regarding prescriptions, including medication assisted therapies, and ensure continuity of care with an outside community-based behavioral health treatment provider. Participants are released with a copy of this plan and provided details on next steps in key areas of reentry (i.e., housing, medical care, and employment). This plan is also forwarded to participants’ probation or parole officers after appropriate release of information forms are signed.