Services Integration:
Strengthening Offenders
and Families, While
Promoting Community
Health and Safety
Shelli Rossman, The Urban Institute
This paper was produced for a conference funded by the U.S. Department of
Health and Human Services on January 30-31, 2002. The views expressed herein
are those of the authors, and should not be attributed to the U.S. Department of
Health and Human Services, or the Urban Institute, its trustees, or its funders.
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Services Integration: Strengthening Offenders and Families,
While Promoting Community Health and Safety
Introduction
Offenders often experience multiple problems,
such as health and mental health illnesses,
the breakdown of family structures, and unemployment
or low income leading to difficulties in
accessing or sustaining services to meet their basic
needs. In some cases, the adversity offenders confront
affects only them and their families. However,
often the impact is more widespread, negatively
impacting the larger community. For
example, some health conditions (e.g., asthma,
diabetes, heart disease, or high blood pressure)
primarily affect the quality of life of the offender
and his/her family or household; the impact on the
community is largely limited to strains potentially
introduced by increased need for health services or
funding to treat those who lack health care coverage.
Others health issues, however -- such as human
immunodeficiency virus/auto immunodeficiency
virus (HIV/AIDS), Hepatitis B and C
(HBV and HCV, respectively), sexually transmitted
diseases (STDs, such as syphilis, gonorrhea,
and chlamydia), tuberculosis (TB), severe psychiatric
disorders, and substance abuse -- not only
disproportionately affect offenders in correctional
facilities and in the community (Hammett et al.,
1999), but also pose potential threats to the wellbeing
of family members and the public as inmates
return to the community.
Single agencies are unlikely to have the human
or fiscal resources to fully address the diverse
needs of offenders and their families -- unless, of
course, the agency deliberately has implemented
case management procedures and erected partnerships
to span organizational boundaries, or developed
a "one-stop shop" model of service delivery.
As Hammett et al. (1999) suggest, an integrated
continuum of care with continuity of providers is
probably the best approach for addressing the
medical and psychosocial needs of offenders in
correctional facilities and as they return to their
home communities.
Service providers should consider addressing
offenders' needs for service as critically important
because of how heavily they impact the well-being
of the entire community. The community can
benefit greatly by investing in treatment and supportive
services for ex-offenders (and their families)
that demonstrably reduce recidivism, which
entails harm to local property and people and
engenders huge social costs for crimes committed,
conviction, and incarceration of offenders (Jacksonville
Community Council, Inc., 2001). In addition,
improving the community-based service delivery
for offenders also benefits other segments
of society who depend on the same service net-
work.
Recent research underscores the importance
of pre-release preparation and initial post-release
support in reducing offender recidivism (Nelson
and Trone, 2000). The National GAINS Center for
People With Co-Occurring Disorders in Contact
With the Justice System, for example, has identified
four key components to promoting successful
re-integration, sometimes referred to as the
"APIC" model. These include:
• Assessment of offenders' clinical and social
needs, and the risks they pose to public
health and safety.
• Planning for the treatment and services required
to address these needs.
• Identifying required correctional and community
programs responsible for post-
release services.
• Coordinating the transition plan to ensure
appropriate service delivery and mitigate
gaps in care.
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Inter-agency collaborations, such as the one
implied by the APIC model, have attracted considerable
interest in recent years as vehicles for
introducing more comprehensive service provision,
while redressing fragmentation in health and
human service systems. Service fragmentation is
characterized by numerous, uncoordinated programs
(with different administrative structures,
rules, and eligibility criteria) resulting in such
problems as delayed service delivery, inadequate
responses, or, in some instances, failure to provide
needed services. One factor contributing to fragmentation
is the limited focus of many programs
that seek to prevent or mitigate specific, often narrowly-defined
problems or behaviors, rather than
responding holistically to the needs of individuals.
While there are various explanations for the existence
of fragmented systems (e.g., tightly constrained
organizational missions or reliance on
categorical funding), there is growing recognition
that collaboration across institutional lines may be
beneficial not only in addressing the multi-faceted
needs of clients who require health and human
services, but also in making more efficient use of
limited agency resources (Morley et al., 1998).
Integration of services occurs at the systems
level, involving the coordination of policies and
procedures of different institutions to achieve a
multiorganizational infrastructure designed to ensure
that individuals do not "fall through the
cracks" formed by the boundaries of various institutional
domains and service providers. Major objectives
of services integration include:
• Identifying gaps in service delivery and assigning
organizational responsibility for
implementing needed services.
• Reducing barriers to obtaining services
(e.g., streamlining applications procedures,
reducing geographical distance between
provider and client, decreasing unacceptably
long waiting periods before treatment
commences).
• Conserving institutional resources by sharing
some efforts across systems or by reducing
unnecessary duplication of efforts.
Services integration necessitates the development
of collaborations across public agencies, or
between public and private organizations. Such collaboratives
may facilitate service coordination using
various mechanisms, including: centralized intake,
assessment, or referral; increased information
sharing, possibly using transparent or linked management
information systems; cross-disciplinary
training and case staffing; joint fund-raising or resource
sharing; and co-location of staff.
Medical and Psychosocial Issues that
Shape Individual and Family Service
Needs
Inmates have more health and psychosocial
problems than the general populace. Factors that
contribute to diseases among offenders include
high-risk lifestyles, such as (Field, 1998; McVey,
2001; Nicodemus and Paris, 2001):
• Heavy use of tobacco, alcohol, and drugs.
• Injection drug use, or tattooing.
• Multiple sex partners.
• Unprotected sex, in or out of prison.
• Transience, particularly if it involves home-
lessness.
• Financial instability.
• Poor or delayed access to health care and
treatment
• Emotional circumstances characterized by
the lack of supportive relationships.
• Overcrowded conditions, and movement
among prisons that spreads contagion.
Although some offenders first experience
health, mental health, and psychosocial problems
in prison, the fact remains that most enter the
criminal justice system with problems that span
multiple domains. Prior to incarceration, most offenders
have been seriously underserved in terms
of medical care, drug treatment, and psychosocial
needs in the community (e.g., many had not received
primary medical or dental care in years
(Hammett et al., 1999).
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The 1997 Survey of Inmates found that
nearly 31 percent of males, and 34 percent of females,
reported a physical impairment or mental
condition: 10 percent had physical problems, 10
percent reported emotional or mental conditions,
10 percent reported learning disabilities (e.g., dyslexia
or attention deficit disorders), 4 percent had
speech disabilities, 6 percent had difficulty hearing
normal conversations even with hearing aids, 8
percent could not see ordinary newsprint while
wearing glasses. Taken together, 25 percent reported
either that they had multiple impairments
or that the nature of their impediment limited the
kind or amount of work they could do (Maruschak
and Beck, 2001). Overall, McVey (2001) estimates
that 25 to 40 percent of inmates have significant
health care conditions that require continuity
of care upon release to the community.
Facilities within the federal prison system are
accredited and routinely surveyed by the Joint
Commission on Accreditation in Health Care Organizations
(JCAHO); however, national uniform
standards are not applied across all state correctional
facilities. Accreditation of facilities within
individual states may be mandated by their respective
governing bodies, but there is no single entity
to which all facilities are accountable. As a result,
health services offered to incarcerated individuals
vary significantly.
Despite limitations, the criminal justice system
often represents the primary route to health
and human services that offenders receive: poor
health due to long-term neglect may be addressed
for the first time during long incarcerations. Thus,
some will return to the community in better condition
than when they entered prison. Others, however,
will continue to struggle with unresolved
pre-existing conditions, experience deterioration
in health exacerbated by prison circumstances, or
contract new diseases while incarcerated.
Relatively little attention has been focused on
proactive prevention in either the correctional environment
or when offenders return to the community.
Virtually all inmates and their families
could benefit from wellness education emphasizing
adequate and consistent medical care, disease
prevention, and nutrition. In addition, female offenders
and female partners of male offenders
might benefit from receiving information on family
planning and prevention of domestic violence.
Individuals who have chronic health conditions
requiring medication or other treatment --
and those who have, or are at risk for, communicable
diseases -- need to be assessed and given
satisfactory care while imprisoned. In addition,
they should be linked with community-based providers
who can continue to support and adjust
their health regimens, as necessary, when they exit
the facility. Typically, employment -- with benefits
or sufficient income to cover fee-for-services -
- is a prerequisite for accessing community-based
health care. Therefore, to avoid disruptions in access
to health care, inmates who do not have jobs
awaiting them when they return home should receive
assistance in obtaining needed identification
and in filling out and submitting applications for
Medicaid, prior to leaving the facility. Other transition
planning should include arrangements to ensure
that:
• Medical records can be transferred from the
correctional facility to community-based
providers.
• Offenders will be supplied with reasonable
amounts of prescribed medications to tide
them over during their early days in the
community.
HIV/AIDS. Prison rates of HIV positive and confirmed
AIDS cases are five times the rates in the
U.S. general population; increases in incarceration
coupled with high rates of HIV infection present a
public health challenge (Holmes and Davis; Ma-
ruschak, 2001). At the end of 1999, 3.4 percent of
females and 2.1 percent of males (i.e., 24,607 inmates
or 2.3 percent of the total population) in
state prisons were HIV positive. However, there
was considerable variation across states: 50 percent
were concentrated in New York, Florida, and
Texas. Thus, the 7,000 inmates known to be HIV
positive in New York accounted for more than 25
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percent of the nationwide total, and 9.7 percent of
the state's custody population. In three states,
more than 20 percent of female inmates were HIV
positive: Nevada (30.6 percent), District of Columbia
(22.4 percent), and New York (21.5 percent)
(Maruschak, 2001).
As Hammett et al. (1999) note, policies for
HIV counseling and testing have assumed increasing
importance given the promising results of
early intervention with antiretroviral therapy. HIV
antibody testing policies vary across correctional
facilities, but virtually all systems offer HIV testing
on request or if there is clinical indication warranting
follow up. Only 17 states mandate such
testing either at intake or release.
Despite the fact that 79 percent of inmates reportedly
had been tested in 1997, there are some
concerns about the heavy reliance on voluntary
testing in prison settings (Hammett et al., 1999;
Zack et al., 2000):
• Many individuals who are truly at-risk are
in denial, and will not seek testing. They
may well continue to engage in high-risk
behaviors while incarcerated, and they are
likely to do so without the opportunity to
access condoms or other prevention protocols
that are available to the outside com-
munity.
• Others may avoid testing and counseling
because of confidentiality concerns. Inmates'
concerns for confidentiality may be
more heightened than those of the general
populace, precisely because they are incarcerated
and unable to choose service providers
they trust.
A related, and serious, concern for children
and families, exists with regard to female inmates.
Given that AZT treatment significantly reduces
perinatal HIV transmission, 1995 Public Health
Service guidelines recommend routine counseling
and voluntary testing of pregnant women as early
as possible. Nevertheless, fewer than half of state
correctional systems routinely test all incoming
women for pregnancy, although 84 percent test on
request, and all test if there are clinical indications.
Overall, state systems typically have the same policy
for HIV testing of pregnant women as they do
for all inmates; only seven states have mandatory
or routine HIV testing for pregnant women, and
voluntary or on-request testing for other new inmates
(Hammett et al., 1999) Thus, review of HIV
and pregnancy testing policies is desirable given
current standards for treating HIV/AIDS.
While HIV and STD educational programs
for inmates are becoming more widespread in correctional
facilities, some gaps remain (Hammett
et al., 1999):
• 71 percent of state/federal systems mandate
HIV/STD education for incoming inmates;
20 percent mandate such training at release,
and 51 percent report that participation is
voluntary at release.
• However, few have implemented comprehensive
or intensive HIV prevention programs.
For example, while 60 percent of
state/federal systems offer multisession
prevention counseling in at least one of
their facilities, only 31 percent of facilities
incorporate such intensive approaches.
• Approximately 86 percent of facilities offer
pre- and post- HIV-test counseling. Basic
information on disease and the meaning of
test results tend to be covered; however,
topics pertinent to behavioral risk reduction
-- safer sex practices, negotiating safer sex,
safer injection practices, triggers for behavioral
relapse -- are less commonly covered
(except in multisession programs, where
such discussions are more likely).
• The 1997 NIJ/CDC survey of HIV/AIDS,
STDs, and TB in correctional settings revealed
that 39 percent of state and federal
facilities were not providing instructor-led
HIV/AIDS sessions. In addition, 87 percent
were not providing peer- led programs
(Hammett, 1998). Peer-based services and
prevention education programs can be cost-
effective: peers often have more inherent
credibility with offenders than correctional
staff or health practitioners (Hammett et
al., 1999). Peer educators can offer formal
and informal services and support, such as
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introductory workshops (e.g., AIDS 101),
individual and group risk-reduction counseling.
They can organize informal networks
for those receiving treatment or in
need of emotional support. And, an added
benefit is that peer leadership skills may
open the door for offenders to find employment
in the community in service organizations
that serve advocacy or prevention
education functions.
Offenders who are HIV positive or living
with AIDS have considerable needs for health care
and social support. Many learn their health status
while incarcerated. Under such circumstances, release
from prison marks the first time these individuals
will have to manage the physical and emotional
challenges of living in the community with
a chronic or terminal illness (Conly, 1998). Like
other offenders returning from incarceration, they
may have no established network for health care,
and also may be lacking an adequate social support
system. Many return with inadequate information
about sources of treatment and about
transmission prevention that will protect their lives
and the lives of others with whom they interact.
Other Communicable Diseases. Recent outbreaks
of communicable diseases in correctional
settings (e.g., TB in three Alabama state prisons in
1999 and in South Carolina in 2000, and HBV in
Georgia in 2001) underscore the importance of
identifying communicable diseases, educating inmates
and staff, and ensuring provision of appropriate
treatment (Nicodemus and Paris, 2001).
Nevertheless, very little information is available
about the transmission of communicable diseases
in prison, or regarding the spread of prison-
incubated diseases to the outside community.
Less is information is available with respect
to STDs, HBV, HCV, and TB in prison populations
than is known about HIV/AIDS, reflecting
the relative rarity of screening for these infections.
For example, testing for STDs appears to be less
widespread than for HIV/AIDS. Approximately 88
percent of state/federal systems have instituted
mandatory or routine testing for syphilis at intake;
16 percent have mandatory testing for gonorrhea;
and 8 percent conduct mandatory screening for
chlamydia (Hammett et al., 1999).
Behavioral profiles and anecdotal reports
consistently suggest that inmates are a high-risk
group that is disproportionately infected with
STDs; however, there is markedly little data available
from state systems to document this. Although
the policies of most state correctional systems
require mandatory or routine screening of
inmates for syphilis, 64 percent of state/federal
systems did not report rates for this infection on
the 1997 NIJ/CDC survey of HIV/AIDS, STDs,
and TB in Correctional Facilities. Systems that
provided information reported syphilis positivity
rates of less than five percent (Hammett et al.,
1999). Correctional systems apparently make even
less attempt to routinely screen for gonorrhea or
chlamydia (73 percent of state/federal systems do
not have mandatory or routine gonorrhea screening,
while 80 percent do not have mandatory or
routine screening for chlamydia); however, those
that do screen reported positivity rates of less than
five percent for incoming inmates (Hammett et al.,
1999).
Hammett et al. (1999) suggest that despite incomplete
data, HBV and HCV are believed to be
higher among inmates than the general population.
Various studies report 22 to 41 percent of inmates
were positive for HCV. HCV antibody positive
rates are particularly high among IDUs and HIV-
positive inmates; for example, 70 percent of female
IDUs in a study of the Connecticut prison
system were HCV positive, as were 36 percent of
their sexual partners (Hammett et al., 1999).
The incidence of TB increased in the 1980s
and early 1990s, spurring concerns not only because
of the resurgence of the disease, but also because
some cases -- including a 1991 outbreak
among New York inmates -- were multidrug resistant.
More recently, the incidence of TB has declined
in both the general population and the inmate
population. However, the incidence remains
higher among inmates; improvements are needed
in use of directly observed therapy, as well as sup-
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port systems to monitor post- release adherence to
treatment for TB disease and illness (Hammett et
al., 1999).
Mental health. Estimates of the prevalence of
mental illness among state prisoners vary widely,
with some suggesting that more than one-third of
the population have some degree of mental health
impairment. Existing mental illnesses may be exacerbated
by incarceration, and conditions of incarceration
may precipitate mental illness: prolonged
idleness; the constant threat of violence;
feelings of guilt, hopelessness, or helplessness
may all contribute to psychological disorders.
Based on inmates who reported either a mental
or emotional condition or an overnight stay in a
mental hospital or program, Ditton (1999) estimates
that 16 percent of the individuals incarcerated
in state prisons are mentally ill:
• 53 percent were incarcerated for violent of-
fenses.
• 69 percent were under the influence of alcohol
or drugs at the time they committed
the current offense.
• 20 percent had been homeless in the year
preceding their most recent arrest.
In addition, more than 30 percent of mentally ill
male offenders and 78 percent of females reported
prior physical or sexual abuse (Ditton, 1999;
Ortiz, 2000).
Roughly 12 percent received mental health
therapy or counseling in 2000, and 10 percent received
psychotropics, including antidepressants,
stimulants, sedatives, tranquilizers, or other antipsychotic
drugs (Beck and Maruschak, 2001; Fa-
belo, 2000). Such estimates likely underestimate
the need for mental health intervention since some
individuals may refuse to participate or be ineligible
to receive services; for example only 61 percent
of mentally ill inmates reported receiving
counseling, medication or other mental health services
in prison (Ditton, 1999; Fabelo, 2000).
Between 15 and 20 percent of inmates who
experience mental health difficulties, particularly
those requiring psychotropic medications, have
sufficiently serious disorders to require continuity
of care (McVey, 2001). Older offenders, and those
released after periods of incarceration, may experience
depression, isolation, or loneliness, all of
which can contribute to difficult community reintegration
McVey (2001). Often, offenders returning
to the community confront multiple challenges,
including homelessness, unemployment,
substance abuse, and impaired physical health
(Conly, 1999).
Without adequate continuing care that coordinates
treatment in prison with community-based
services, released offenders are likely to deteriorate
and run the risk of returning to prison.
Depending on the services received while in
prison, offenders released to the community may
need periodic re-assessment; continuing or new
medication; or linkage to therapeutic and support
groups.
Many mentally ill offenders are poorly
equipped to advocate for their own welfare. Those
who are fortunate can turn to family and friends
for assistance in this regard; although such informal
support networks may require preparation to
effectively assume advocacy roles.
Also, mental illnesses often place severe
strains on personal relationships. Thus, some offenders
are estranged from family and friends,
sometimes directly related to unstable or antisocial
behavior stemming from their mental or
emotional state. In such cases, offenders may require
assistance managing not only their mental
health needs, but also their efforts to re-build viable
family and friendship networks.
Substance Abuse. While various studies capture
offender self report of substance use, few studies
systemically address the prevalence of drug abuse
and drug dependency/addiction disorders in correctional
facilities, as defined by the American
Psychological Association's Diagnostic Statistical
Manual, fourth edition (DSM-IV) (Mears et al.,
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2001). Nevertheless, substance abuse disorders
are perceived to disproportionately affect incarcerated
individuals: a recent study suggests that
although only 21 percent of state inmates had drug
convictions as their most current offense, 83 percent
had some history of illegal drug use, and 70
percent reported having used drugs regularly (i.e.,
at least once weekly for a period of at least one
month) prior to incarceration (GAO, 2001). Further,
this population is significantly undertreated:
• With the exception of detoxification, most
offenders have not received treatment in the
community (Field, 1998).
• Only about 24 percent of offenders in state
prisons participated in drug treatment programs
while incarcerated (GAO, 2001).
• A SAMHSA study suggests that nearly half
of state prisons offer no treatment, and even
where treatment is provided, the programs
are minimal and generally not provided in
the segregated settings that have been found
to be most effective. Thus, substance-
abusing offenders returning to the community
are at high risk of relapse, and possibly
crime (GAO, 2001).
Periods of incarceration provide opportunities
for treatment; however, treatment that stops with
release from prison may not be effective: those
who are coerced into treatment and remain substance
free while in prison still are at great risk of
relapse and recidivism when released (Field,
1998) . Such individuals require a variety of services
to support continued sobriety; and, at minimum,
their family or informal support networks
need to understand how to avoid enabling substance
abuse.
Basic Survival, Family Dynamics, and Other
Psychosocial Issues. Offenders are a diverse
population, but they display certain common characteristics:
low income, low level of education,
disrupted home and family life, low level of job
skills and employment experience, and alcohol or
drug addiction. Aside from medical, mental
health, and substance abuse treatment, the key
service requirements for those returning to the local
community are related to immediate basic
needs (food, shelter, clothing), ongoing personal
support, housing, education, employment, and legal
assistance. Correctional facilities offer some
programs that assist offenders with meeting these
needs. For example (GAO, 2001):
• 38 percent of inmates participated in education
classes.
• 31 percent participated in vocational training
programs, including in-class training or
on-the-job training (not including institutional
job assignments).
• 3 percent worked in income-producing
prison industry jobs; although 60 percent
had some work assignment (such as food
service, laundry, grounds maintenance).
• 12 percent participated in pre-release programs
covering such topics as: budgeting,
stress reduction, and job interviewing skills.
These programs are necessary, but not sufficient to
provide the level of assistance offenders require.
Offenders returning to the community are in
need of safe, affordable housing. Some can return
to the households they occupied prior to incarceration,
or can find suitable accommodations with
family or friends. However, many returning offenders
are homeless -- a fact they may try to conceal
to avoid delaying their early release. Some
may need emergency shelter immediately on release,
others may require transitional housing
while gaining life, educational, and employment
skills. Transitional housing services have an added
benefit -- often they help offenders to establish
residency credentials that facilitate their access to
other needed services.
Families generally are expected to be the first
line of defense in providing on-going personal
support to their members; however, families of offenders
sometimes are ambivalent about relatives
returning to the community (Denckla and Berman,
2001; Jacksonville Community Council, Inc.,
2001; Nelson and Trone 2000). Often the period
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of incarceration, the location or regulations of the
facility, or the offender's own behavior have created
physical or psychological distance. There
may be unresolved issues related to harms inflicted
on family members by the offender prior to
incarceration. Newly released offenders may be
unable to respond appropriately. Under stress,
those with histories of violent behavior may lash
out physically or emotionally. Parents who have
been incarcerated may have added problems of reconnecting
emotionally with their children, reestablishing
custody rights or gaining visitation
privileges, and covering financial support. Needed
family services may include: family therapy, anger
management, parenting classes, family bridge
building and child reunification.
Offenders also need to acquire basic life
skills, such as: time management, financial management,
communication skills, problem solving,
anger management and conflict resolution, and
decision making (Nelson and Trone, 2000;
Rossman et al., 1999). Many people who end up in
prison have impaired judgement -- they need to
learn to wait before acting, consider several alternatives,
and choose wisely among different
courses of action. Cognitive-behavior therapy,
which has become increasingly common in correctional
environments, can help offenders acquire
better skills. Nelson and Trone (2000) suggest that
exposure to this type of intervention can help at
any time, but is especially useful close to release.
Legal advice and assistance available during
incarceration, or immediately thereafter, could
help offenders anticipate and deal with legal issues
before they spiral out of control (Jacksonville
Community Council, Inc., 2001). For example,
changes in family situations may warrant legal action.
Offenders may want or need a divorce; or
they may have to deal with property transfers.
During their incarceration, fathers may not have
paid child support, triggering legal actions; they
may need to ask the court to alter payment requirements.
Parental custody may have been lost
or may require court action to re-establish.
Additionally, offenders may lose certain civil
rights, and need legal assistance to understand the
eligibility requirements and to petition the court to
have their rights re-established. For example, Florida
is one of 13 states that permanently disenfranchises
ex-felons unless they are specifically
granted clemency, for which those with only one
felony conviction are eligible (Jacksonville Community
Council, Inc., 2001). Only 24.5 percent of
those eligible for clemency had it granted in l998-
99. Applicants were denied if they still owed on
sentence-imposed fines or had other outstanding
debts that could be used to question their "readiness"
for full citizenship. Some have questioned
the constitutionality of this practice; nonetheless,
this restriction on ex-felons diminishes their ability
to rebuild lifestyles as stable productive citizens
in the fullest sense -- and also undermines the
civic life of communities impacted by high felony
rates.
Collaborations Among Criminal
Justice System and Health and
Human Service Systems to Meet
the Needs of Returning Prisoners
and Their Families
Historically, corrections systems have focused
their efforts only on offenders during the
period of their incarceration, concentrating on
such key concerns as security and classification, as
well as some basic services, including: limited
education and vocational training, basic health
care, and the provision of some counseling
(McVey, 2001). As such, the major concerns of
correctional agents have been the offender -- exclusive
of family considerations -- and protection
of public safety. Consequently, few services were
extended to families; in fact, family advocates often
point to various prison policies or practices
that adversely affect families (e.g., movement of
offenders to facilities that a great distance from
their home community, entrance procedures that
are intimidating to visitors, waiting areas that are
not family friendly).
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For the most part, state corrections systems
really have not forged seamless connections to
community-based criminal justice entities, much
less to health and human service systems. For example,
in evaluating the community-based case
management model implemented to serve substance-
abusing felons returning to targeted communities,
Rossman et al. (1999) found that correctional
facilities often did not even inform
probation officers (POs) in advance of inmates'
impending or actual release. Instead, prison administrators
relied on offenders to report to their
POs within stipulated time frames (e.g., 72 hours
after return to the community). Although most
complied, some did not, resulting in long time lags
before individuals were linked to planned services.
Relatively little attention has been paid to developing
substantial partnerships with health and
human service providers or to linking inmates
with community-based services. For those discharged
without any further requirements for supervision,
there is no guarantee that any entity will
assume responsibility for assessing individual
needs across different service sectors or for ensuring
that needed services are forthcoming.
Individuals released with community supervision
requirements, on the other hand, become
the responsibility of the probation/parole system.
Although probation and parole departments have
varied across time and place, they typically have
provided some direct or sub-contracted services to
returning offenders, in addition to fulfilling their
monitoring and oversight functions. Some offenders
-- such as sex offenders and others assigned to
specialty caseloads -- may receive more varied
services, as well as increased service intensity.
However, such involvement usually is not predicated
on robust services integration across institutional
lines, nor has it reached the level of comprehensive
case management. In general, POs
have huge caseloads, and are focused on primary
mission of public safety, rendering them unlikely
to provide the intensive, individualized assistance
needed by many offenders.
In addition to parole and probation agencies,
departments of health, alcoholism and substance
abuse, labor, and social services have a stake in
improving what happens to inmates after release --
since returned offenders comprise much of these
organizations' client base. However, staff in these
systems generally have had little or no access to
inmates prior to their release. As Nelson and
Trone (2000) suggest, involving such agencies in
the custody side of programming could improve
outcomes by creating a more transparent system of
continuous care. In addition, correctional systems
can benefit from both the infusion of expertise
available from other substantive domains and the
additional resources that may translate into
stronger prison programs and services.
Increasingly, correctional systems have exhibited
interest in developing partnerships with
other institutional stakeholders (e.g., state health
departments, community-based service providers)
to conduct health screening, deliver health education,
or incorporate transition mechanisms such as
release planning. Nevertheless, these efforts often
fall short of achieving the goal of meaningful and
seamless transition and provision of care for returning
offenders with extensive health, mental
health, and psychosocial problems. Typically,
prison and parole systems' functional boundaries
are not adequately integrated with one another --
and also are not sufficiently integrated with health
and human service systems -- to achieve seamless
transition (McVey, 2001).
Barriers to Coordinating Prison and
Community-Based Services
Barriers to coordinated care exist at both the
level of individual clients and at institutional/service
system and staff levels. Client barriers
include (Holmes et al.; Rossman et al., 1999):
• Anticipation of rejection by service agencies
based on prior difficulty in trying to
negotiate system requirements.
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• Desire to deny the reality of their at-risk
behaviors or their need for medical/mental
health intervention.
• Distrust of providers, or of services (e.g.,
some subcultures are biased against accepting
mental health services).
• Poor decision making and often irresponsible
choices.
Various factors can impede service coordination
from prison to the community, or services integration
within the community. Correctional
institutions often are highly independent and
resistant to change; correctional officials have to
be willing to open their facilities to outside organizations
(Hammett, 1998; Holmes et al. ).
Also, because prisons are frequently located a distance
from the community to which offenders are
returning, state agencies and community-based organizations
sometimes adopt an "out of sight, out
of mind" perspective: they don't serve the inmates
in prison, and do not come to regard them as potential
clients (McVey, 2001).
Different organizational missions and "corporate
cultures" have to be negotiated. Correctional
facilities and community-based service agencies
(public welfare, probation and parole, health and
mental health, and other social service providers)
have individually mandated responsibilities, which
they have become used to unilaterally completing.
They may lack information that facilitates collaboration,
or they may be operating on questionable
information that undermines interest in collaborating.
For example:
• As part of their legal mandate to make reasonable
efforts to reunify families, child
welfare case workers are obligated to facilitate
links between parents and children,
even when parents are incarcerated. Thus,
for example, caseworkers need to prepare
and support kinship and foster families to
deal with: 1) children's psychosocial needs
related to parental dysfunction; 2) challenges
to parent-child contact during parental
incarceration; and 3) preparation and
planning for family reunification, or if that
is not possible, permanent placements. In
addition, caseworkers are expected to help
parents access services that will assist them
in properly parenting their children while
they are incarcerated and post-release. As
Seymour (1998) notes: case workers may
recognize parents' service needs, but have
little knowledge of services available
within prisons, or have difficulty linking
parents to these services. In addition, geographic
distance, prison security requirements,
and high caseloads may impede case
worker-parent communication.
• Denckla and Berman (2001) suggest that
the behavioral health treatment community
(e.g., state and county agencies of mental
health, mental retardation, substance abuse,
and the programs they fund, including psychiatric
hospitals and community-based
service providers) historically has shied
away from addressing the issue of people
with mental illness who have repeated contacts
with the criminal justice system.
Community-based providers often find
mentally ill offenders challenging to serve
because of their co-existing conditions,
non- compliance, unkempt appearance, and
their clinically difficult and challenging
presentation (Conly, 1999). Further, providers
often do not have experience in treating
"forensic clients." Where providers can
select their own clients, they frequently
avoid offenders, who they associate with
disruptive or violent behavior. As a result,
people coming directly from the criminal
justice system may be underserved because
staff: fear for their own safety and that of
other clients; perceive forensic clients as
having a host of very severe problems that
are difficult to treat effectively; recognize
the more challenging cases are likely to require
more expensive resources (e.g., hospitalization);
and worry that treatment failure
may jeopardize funding that is performance
based (Denckla and Berman, 2001).
Institutional staff also may be put off by "cultural
clashes."Hammett (1998: 9), for example,
notes that there "real differences between the phi-
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losophies, perspectives, and priorities of public
health and correctional agencies that can make
collaboration difficult if they are not sensitively
handled":
• Correctional staff have a primary mission of
security -- protection of inmates, staff, and
visitors from violence. Care providers are
concerned with health status and quality of
life of individuals. The social work view of
client self-determination may not be valid or
safe, and may well conflict with criminal
justices policies. For example, community-
based health prevention educators often try
to improve clients' independent decision
making and self-efficacy skills; however,
prison staff may be concerned that empowering
inmates in this way will undermine
discipline and order in the facility.
• Similarly, community-based providers addressing
issues such as HIV/AIDS or STDs
may adopt harm reduction -- rather than abstinence-based
-- models. Therefore, they are
prepared to educate individuals on when and
how to use condoms during sexual encounters
or how to reduce risks associated with injection
drug use by cleaning needles and works.
Such information is antithetical to criminal
justice policies; for example, only two state /
federal systems make condoms available
(Hammett et al. 1999). Further the harm reduction
stance may be particularly troubling
to some correctional officials since sexual and
needle-using activities (e.g., drug use and tattooing)
are expressly prohibited in prison, and
administrators may not want to acknowledge
the existence of such problems on their prem-
ises.
Resources are always a concern. Inflexible or
inadequate funding is frequently cited as a major
impediment to coordination of services within and
across institutional systems. In addition, limitations
on physical plants and manpower may undermine
both correctional institution and service
system capacities to offer enhanced services (e.g.,
there may be no infrastructure or space available).
Other logistical issues impede coordination; for
example, uncertain release dates complicate transition
planning (McVey, 2001; Rossman et al.,
1999).
Adequate in-prison resources are needed to
assess and treat inmates, and to prepare transition
plans. Resources also must be found to support
community-based service delivery where offenders
are unable to cover "fees-for-services." Often,
resourcing is hampered by inadequate understanding
of post-release assistance entitlement. For example,
Medicaid and Social Security Income (SSI)
may be viable approaches to securing funding for
long-term health and mental health care for some
offenders. However, associated paperwork is
cumbersome and unfamiliar, and it can take
months to process applications during which time
needy people may not be receiving medical services,
housing, etc. Applications should be initiated
well in advance of release dates (states differ
in processing time, but several months should
probably be expected). Cooperative agreements
should be established between Departments of
Corrections and state agencies administering entitlement
programs, such as Medicaid, with the goal
of avoiding care interruption upon release; for example,
transition planning should try to have
Medicaid approval within two days of release to
ensure continuity of medication renewal and
health monitoring/treatment.
Information sharing across systems is notoriously
troublesome -- data-sharing agreements
across systems typically are not in place (Morley et
al., 1998; Rossman et al., 1999). Record keeping is
often scanty or erroneous. For example, Jacksonville
Community Council, Inc., a nonprofit, nonpartisan,
civic organization that seeks to improve quality
of life based on informed participation of
citizens undertook a local study to strategically plan
for improved community responses to the need of
returning offenders. They reported considerable difficulty
in obtaining information from the county
and state corrections systems that would allow them
to be proactive (Jacksonville Community Council,
Inc., 2001):
• The state system was unable to provide data
on offender needs with respect to emer-
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gency spending money, clothes, or personal
identification when released from prison;
the state system only was able to indicate
what they provide offenders upon release:
$100, clothes if needed to wear at release
(and the costs are deducted from the $100),
and a corrections department picture id.
• DOC could not provide information on the
proportion who have a home to return to,
those financially capable of paying rent or a
mortgage, or those ready after period of incarceration
to assume responsibilities of
rental or home ownership.
• The state system reported about 58 percent
tested at less than 5th grade reading level; it
could not provide data on degree of literacy
or advancement in education classes during
incarceration, nor was information available
on the marketable skills of those returning
to the community.
• Information was not available on the percentage
who have jobs to return to when
they are released, or the number who have
physical disabilities, mental illness, or other
conditions that limit their ability to work
competitively. The state provides a bus
ticket upon release to offender's destination
of choice within the state; no information is
available on those who have access to cars
or cannot use public transport due to location
or limitations.
• The state is aware of the incidence of certain
health conditions because of the importance
of treating them to maintain health
and order within the correctional facility,
but apparently is not aware of those who
lack health insurance or the ability to pay
for care when released
• Data were not available on the percentage
of offenders who have families to return to;
the degree to which families are functional
and supportive; the percentage of offenders
who have minor children, are required to
pay child support, have officially lost custody
of children, or the status and location
of those children.
Inmates and offenders returning to the community
tend to be fairly mobile (e.g., prisoners are
often transferred from one facility to another;
while those in the community experience unstable
housing situations). Personal information should
go with them as they move within correctional facilities
and throughout the community; however,
in many cases, vital medical records (including
test results and medication status) and other information
relevant to service coordination are
never sent to new health and human service providers,
or are seriously delayed. Information may
be manually recorded, making it difficult to share
widely across different organizations and staff. Or,
it may be automated, but subjected too long delays
prior to data entry, rendering the information
obsolete by the time it is accessible.
Putting families into the mix represents a new
approach for some agencies, challenging them to
find effective ways to work with and engage family
members. Staff may need to re-think the assumptions
that service systems have made about
families: Who should be included in family? Who
should determine what is right for family members?
Should involvement be coerced or voluntary?
Service provision across different domains
hold different perspectives and may be challenged
to achieve consensus.
Barriers to Service Delivery
at the Local Level
Barriers to services integration at the local
level occur for a variety of reasons (Jacksonville
Community Council, Inc., 2001; Morley et al.,
1998; Rossman et al., 1999). Significant gaps exist
between offender needs and locally available resources.
There may be deficiencies in the spectrum
of services; insufficient resources to address
the full need; a changing landscape of local service
providers, and high staff turnover in the service
sector, that undermine stable cross-agency
interaction; and an ineffective network of information
sharing to helps offenders become aware of
services and take advantage of them.
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The recent Jacksonville study (2001) identifies
many of the same difficulties encountered by
local OPTS programs as they attempted to implement
case management and services integration
(Jacksonville Community Council, Inc., 2001;
Morley et al., 1998; Rossman et al., 1999). For
example:
• Information is not easily available about existing
services and how to access them. Individuals
with immediate needs experience
a knowledge gap regarding where to go and
how to gain quick access to emergency services.
There is no single, easily accessible,
authoritative source of information. An informal
word-of-mouth, information-sharing
network may exist among offenders, but
not all are connected to it. Returning offenders
need assistance in understanding,
contacting, and obtaining services.
• Services to meet offender needs are fragmented
and not comprehensively available.
A detailed inventory of community-based
resources to meet service needs of ex-
offenders concluded that at least some services
are available locally to deal with each
of the major kinds of needs identified;
however, the spectrum of services is incomplete,
their capacity to serve is limited,
and links between pre-release and post-
release service are weak. Although many
services are provided formally, there are
unknown amounts of informal services. Resource
people generally concurred that as a
whole, even taking informal resources into
account, services are insufficient to meet
existing needs. Additionally, the effectiveness
of formal services is limited by the degree
of fragmentation among service providers,
and by lack of coordination among
providers.
• Data to plan for services are insufficiently
available (see earlier discussion).
• The recent political climate has favored punitive,
over rehabilitative, responses; get
tough on crime attitudes have prevailed.
Consequently, members of the public and
some service providing organizations lack
both an accurate understanding of the needs
and services for ex-offenders, and the political
will to respond appropriately.
Also, certain legal restrictions society feels
justified in imposing have the effect of impeding
efforts of offenders to obtain needed services and
build stable, productive lives:
• Emergency housing is in big demand, but
there are limited beds (Jacksonville Community
Council, Inc., 2001). Offenders who
committed certain kinds of crime are legally
excluded from some housing; in addition,
housing applications for apartment
rental request information about prior convictions
permitting rental agents to informally
discriminate, limiting housing
choices. Some also face informal discrimination
from lenders when they seek to establish
credit for mortgage approval or
apartment rental. Laws requiring notification
of sex offender residence may trigger
some discriminatory reactions.
• Given labor market conditions and generally
limited individual skills, there is a gap
between the wages offenders can earn and
their financial needs. In addition, there are
some limits on employability due to criminal
histories. For example, sex offenders
have limitations on some jobs, by law or
practice (e.g., they can't work in businesses
or agencies serving the public - especially
women and children - directly); those with
theft may not be able to work where there is
money handling.
Promising Models
Several promising models have been suggested.
These models are not panaceas, but provide
guidance in working toward improved services.
Two key features they illustrate are:
creation and maintenance of a coordinated continuum
of service delivery that overcomes
fragmentation, and heavy reliance on mentoring
and case management that provide strong, ongoing
personal support for ex-offenders.
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The AIDS Institute of the New York State Department
of Health collaboration with the Department
of Correctional Services involves a
comprehensive suite of services, including: HIV
counseling and testing, education (including peer
education provided by current inmates and ex-
offenders), and supportive and transitional services
for HIV positive inmates (Hammett, 1998).
Regional teams implemented in 1989 to provide
HIV counseling and education for inmates and
correctional staff were expanded in 1993 to include
community-based organizations. The model
includes an AIDS in Prison Hotline, funded by the
AIDS Institute and operated by the Osborne Association
in NYC. The hotline provides counseling,
education, support, and referral to community-
based services; inmate collect calls are encour-
aged.
The Fortune Society's Empowerment Through
HIV Information, Community and Services
Coordinated Health Care (ETHICS 3/CHC;
New York) program provides transitional services
from prison to community for HIV-positive offenders,
using a family-focused approach, intensive
case management (including crisis intervention,
counseling, and service referral), partnerships
with networked medical care facilities, and formal
and informal social and recreational group interaction
that provides peer support and opportunities
for staff to encourage the development of social
skills that facilitate smoother re-integration into
the community.
All clients are assessed upon release (and
every two months thereafter) and provided with an
initial medical referral; medical services are available
through a linkage agreement with the Institute
of Urban Family Health, although clients often
choose other health providers. Depending on individual
needs, additional referrals may include: financial
benefits, housing, substance abuse counseling,
psychotherapy, food resources, educational
and vocational services, and day treatment programs.
Staff or peer counselors/educators escort
clients to referrals, and case managers confirm acceptance
and monitor on-going participation.
One of the criteria for participation is that offenders'
family must be willing to participate in
the program and access health services through
ETHICS 3. Project staff make home visits to engage
and assist family members, in addition to
hosting family-oriented events (e.g., picnics, parties,
and completion ceremonies). Despite agreement,
families have been less engaged than expected;
reasons for low participation include:
• Offenders' relationships with family members
have deteriorated beyond repair.
• Family members are engaged in other programs
or receive services from other providers
they are comfortable with.
• Family members are willing to offer support,
but at a distance.
• Clients have not disclosed their health
status to family members.
A Rhode Island collaboration involves State
Department of Health, State Department of
Corrections, the Miriam Hospital (medical center
affiliated with Brown University) and 40
community-based organization (Hammett,
1998). Initially funded by the Department of
Health, an increasing share of funding now comes
from the Department of Corrections. Early goals
were to provide treatment and supportive services
for HIV-positive inmates and to facilitate continuity
of care between providers in prison and the
community; subsequently, the program expanded
to address pre-and post-test HIV counseling, discharge
planning, transitional services, and community
linkages for HIV-positive inmates and at-
risk HIV-negative inmates.
A disease investigation specialist, funded by
the Department of Health and based at the correctional
facility, notifies inmates' sexual partners
and performs primarily HIV outreach. This individual
also locates inmates released from the correctional
facility prior to receiving their HIV test
results to link them to services at Miriam Hospital
or another community-based service provider.
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CDC funds two additional public health educators
who provide prevention education within
the correctional facility.
Post-release services include: medical treatment,
housing, substance abuse treatment, job development,
psychological support, and long-term
case management. Evaluation results revealed reduced
recidivism rates for female participants.
Compliance with post-release medical and other
service appointments increased substantially.
Project Bridge in Rhode Island (Holmes et al.,
Holmes and Davis); serven=92) reported that 78
percent of clients were IDUs; 40 percent were
multiply diagnosed with Axis 1 Mental Disorder,
65 percent were homeless at the point of prison
release. All clients are assessed for readiness for
substance abuse treatment, but sobriety is not a
condition of enrollment. Case managers identify
all medications clients are taking, and submit applications
to the state AIDS Drug Assistance Program
to ensure that HIV medications are obtainable
after release. Psychiatric and other non-HIV
drugs have to be secured through other means.
Clients receive a medical appointment within 10
days of discharge; and are accompanied to medical
appointments by the social worker (a social
work assistant generally accompanies clients to
social service appointments) -- this is important to
ensure that clients ask pertinent questions concerning
care.
Clients are considered particularly vulnerable
during the first 24 hours post-release. More often
than not offenders return to same geographic area
where their arrest occurred; their social contacts
revolve around drug use and illicit behaviors.
Therefore, it is critical for case manager to make
contact within the first week, and the first visit is
home-based or in the community.
Physicians who see clients after release are
the same ones who treated them during incarceration,
which ensures continuity of medical care.
The Maryland Community Criminal Justice
Treatment Program (MCCJTP). MCCJTP
brings treatment and criminal justice professionals
together to: screen mentally ill individuals while
they are confined in local jails, prepare treatment
and aftercare plans, and provide community follow
up post release. The program targets those 18
or older who have serious mental illness (i.e.,
schizophrenia, major affective disorder, organic
mental disorder, other psychotic disorders) with or
without co-occur