B ERNALIL ILLO C OUNTY T RANSIT ITION P LA LANNING & R E - ENTRY R ESOURCE C ENTER February 2018 1
T HE P ROBLEM • People transitioning from jail to community • Chaotic and vulnerable time for most individuals • Impacts continuity of care • Housing/Jobs/Relationships are strained or lost • Contributes to recidivism (30 – 65%) • Decompensation, destabilization and overdoses risks • Over-reliance on emergent systems • People leaving jail with Behavioral Health disorders & co-occurring disorders • Increased risk • Higher rates of recidivism and reliance on emergent systems Bernalillo County September 2017 2
TRANSITIONING FROM JAIL TO COMMUNITY • MDC releases approximately 60 individuals/day; 420/week; 1800/month; and 21,000+/year* • More than 40% of MDC population receives some type of care from the Psychiatric Services Unit (PSU); (24+ per day, 168/wk, 8500+/year) • 18% of males and 27% of females in MDC have a SMI diagnosis. 68% of inmates have a drug/alcohol dependency (BJA) • Rapid Releases: Approx 56% of releases are individuals with LOS <72 hours* • Timing of Releases: Approx 64% of releases are during the hours of 4pm – 8am* 3 Bernalillo County February 2018 *based on analysis of a sample of MDC releases from July 2017
T WO C OMPONENTS 1) Transition Planning @ MDC • Screen at booking • Assess moderate & high risk, engage to develop individualized transition plans • Communication/Coordination of supports and services • Accelerated interventions and communication/coordination for Rapid-Releases 2) Re-Entry Resource Center (downtown) • Safe harbor, recharge, prepare • Assess, enroll, connect • Community Health Worker and Navigator engagement • Coordinate with and invite in community providers and organizations 4 Bernalillo County February 2018
C RIMINOGENIC R ISK AND B EHAVIORAL H EALTH N EEDS F RAMEWORK 5
Screen, Assess, Plan 12 Social Service Coordinators (SSCs) METRO DETENTION CENTER Role/activities MDC 8 Transition Planners Role/activities UNMH – Forensic Case Management Transition 2 Discharge Planners Role/activities CCS RRC 8 Community Health Workers Role/activities UNM Health Sciences- CHWI Link COMMUNITY SUPPORT Various Community Service Role/activities Providers/Partners
RRC D ESIGN R ENDERINGS – M AIN R ECEPTION 7 Bernalillo County February 2018
E NTRANCE /R EFRESHMENT A REA 8 Bernalillo County February 2018
RRC L OUNGE 9
RRC O FFICES 10
S ERVICES AT R E - ENTRY R ELEASE C ENTER For All Releasing Moderate Need High Need • • Safe Harbor Meet with case • Health/BH assessment manger / care • Phone • Assignment to coordinator • Charging Station community-based case • Verify Medicaid status manager • Waiting Lounge • Rx retrieval assistance • Housing priorities • Coffee/Snacks • Transition plan review • Resource/Services and initial contacts • Hygiene items • Peer support • Seasonal clothing • Transportation • Bus token arrangements • Rx delivery • Questions/Assistance from floor staff 11 Bernalillo County September 2017
A PPLYING B EST P RACTICES • APIC (Osher & Steadman, & Barr) A ssess P lan I dentify C oordinate Booking Release Post Release • Transition from Jail to Community – TJC (NIC) Level of Service and Coordination. Highest Need Moderate Need 12 Mild Need Bernalillo County February 2018
U SEFUL M ODELS • Cook County, Il – Treatment Alternatives for Safe Communities (TASC) • Discharge Lounge • Supportive Release Center • Portland, Or – Reentry Transition Center • Includes peer mentoring and employment/job skills • Alleghany Cnty, PA – Coordinated Re-entry • Pre/Post release Transition Case Management Bernalillo County February 2018 13
Anticipated Outcomes • Increased engagement in community services • Reduction in use of emergent services/hospitalization • Improved health • Reduction in recidivism • Improved system coordination and realized efficiencies Bernalillo County September 2017 14
A Joint Effort of Bernalillo County Behavioral Health Services Department Metropolitan Detention Center And The University of New Mexico 15
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