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; and housing and homelessness service providers.
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 during the diversion and 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 within the below diagram to view examples of the kinds of information partners in a case management team usually keep in their records about participants and what information the lead case planner should share with and receive from 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.
Opportunities for Collaboration and Information Sharing
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:
- Invitation to participate in reentry/case planning (with permission from participant)
- Participant’s goals
- Who to contact if there are any problems or if they need assistance
- Visiting schedule
- Relapse prevention plan
- Safety plan including community resources for use during behavioral health crises
- Information on appointments, required appearances, and mandated conditions (i.e., court, treatment, community supervision, and other support services)
- Discharge plan and release date
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
- Progress toward family case plan goals, family-based treatment, and or family reunification
- Strategies and resources to support the participant’s reentry and recovery (i.e., housing, transportation to appointments, incentives)
- Updates on participant’s children if support system member has custody
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)
- Family/support system members designated for decision making during emergency medical response (such as living wills) and who may be available to support the participant during significant medical interventions
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 and relapse prevention plan
- 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)
- Description of treatment participant engaged in while in custody
- Family/support system members who can provide recovery-based support (with permission of participant)
- Anticipated date of release and referral information
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
- Family/support system members who can provide recovery-based support (with permission of participant)
- 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)
- Description of treatment the participant engaged in while in custody
- 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)
- Safety and relapse prevention plan
- Family/support system members who can provide recovery-based support (with permission of participant)
- Anticipated date of release and any needed referral information
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
- Crisis response resources available in the participant’s community
- Family/support system members who can provide recovery-based support (with permission of participant)
- 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 and needs assessment information
- Participant strengths
- Documentation detailing valid reasons why a court appearance is missed
- Family/support system members who can provide support for compliance with court appearances and conditions (with permission of participant)
Lead case planner receives the following information:
- Court-ordered conditions
- The disposition of the participant’s case
- Competency status
- Screening and assessment results including criminogenic risk and needs assessment
- Participant’s legal history including rearrests, warrants, and holds
Community Supervision
Lead case planner sends the following information:
- Housing location and contact information
- List of participant’s current medications
- Screening and assessments, including substance use, mental illness, and criminogenic risk and needs
- List of current medications, treatment, and other support services the participant engaged in while in custody
- Participant’s legal status and history, including disciplinary history while in custody
- Release date
Lead case planner receives the following information:
- Conditions of community supervision
- Participant’s community supervision history and current pertinent details that might affect community supervision status and any diversion programming, if applicable
- Community-based treatment and support services resources for use in reentry planning
Vocational, Employment, and Education Support Services Provider
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
- Vocational, employment, and educational programming the participant has attended/completed when in custody
- Long term goals related to career or education
- Referrals to community-based services as part of reentry planning
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:
- Housing referral packages as part of reentry planning
- 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
- Release date
Lead case planner receives the following information:
- Services provided
- Housing rules
- Lease information
- Provider or landlord contact information
- 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 and needs
- Request to do in reach into the correctional facility as allowed, to engage participants pre-release in reentry planning and provide peer support services
Lead case planner receives the following information:
- Updates regarding compliance with conditions of release/diversion or community supervision, when required
- 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
- Strategies for maximizing engagement and compliance with mandated conditions post release