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Collaborative Comprehensive Case Plans

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; housing and homelessness service 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 during the diversion and reentry process. When a specialized housing or homelessness service provider is the lead case planner, the staff member who creates case, service, or treatment plans and conducts case management for program participants may be a housing case manager, housing navigator, social worker, or other housing agency staff member. 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. 

PeerSupport Specializedhousingprovider Vocational andeducationalprovider Correctionalfacillity Communitysupervision Courts Mentalillnesstreatmentprovider Substance usetreatmentprovider Medicalprovider Children’sserviceagencies Participantsupportsystem Participant PeerSupport Specializedhousingprovider Vocational andeducationalprovider Correctionalfacillity Communitysupervision Courts Mentalillnesstreatmentprovider Substance usetreatmentprovider Medicalprovider Children’sserviceagencies Participantsupportsystem Participant Lead Case Planner:Behavioral HealthTreatment Provider PeerSupport Specializedhousingprovider Vocational andeducationalprovider Correctionalfacillity Communitysupervision Courts Mentalillnesstreatmentprovider Substance usetreatmentprovider Medicalprovider Children’sserviceagencies Participantsupportsystem Participant Lead Case Planner:Behavioral HealthTreatment Provider Participantsupportsystem Participant PeerSupport Specializedhousingprovider Vocational andeducationalprovider Children’sservice agencies Correctionalagency Courts Mental Illnesstreatmentprovider Substance usetreatmentprovider Medicalprovider Lead Case Planner:Community SupervisonAgency Participantsupportsystem Participant PeerSupport Specializedhousingprovider Vocational andeducationalprovider Children’sservice agencies Communitysupervision Courts Mental Illnesstreatmentprovider Substance usetreatmentprovider Medicalprovider Lead Case Planner:Correctional Agency Participantsupportsystem Participant PeerSupport Correctionalagency Vocational andeducationalprovider Children’sservice agencies Communitysupervision Courts Mental Illnesstreatmentprovider Substance usetreatmentprovider Medicalprovider Specialized Housing Provider

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 (including past housing experiences, rental assistance, and evictions) 
  • 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 
  • Any formal barriers to housing (including evictions or types of criminal record history) 

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

Children’s Service Agencies (including welfare agencies, schools, day care providers, pediatric health care providers)

Lead case planner sends the following information: 

  • If participant does not have full custody of child or children, the following information may need to be shared with permission: 
    • Treatment attendance and drug testing results 
    • Compliance with court conditions 
    • Employment or education status 
    • Housing status 
    • Child-rearing responsibilities such as school or day care pick-up and drop-off times and any appointment times that could interfere with reporting times 
    • A designated point of contact for assistance with children in case of emergency 
    • Child support requirements 
  • If participant has custody of children, the following information may be shared: 
    • Appointment times for substance use and mental illness treatment, community supervision, and any other appointment times that may conflict with the participant’s own requirements in reentry or diversion 

Lead case planner receives the following information: 

  • If participant does not have full custody of child or children, the following information may need to be shared with permission: 
    • Updates on legal proceedings for child custody 
    • Any changes in requirements or status for regaining custody 
    • Child visitation schedules 
    • Child support requirements 
  • If participant has custody of children, the following information may be shared: 
    • Scheduling information as necessary so that the participant’s reentry or diversion activity schedule does not conflict with parenting obligations, i.e., regular school pickup and drop-off times 

Medical Provider 

Lead case planner sends the following information: 

  • Medical information (if necessary) that would ensure completion of procedures and treatment (with participant consent) 
  • Health care insurance information (if available) 
  • List of current medications, prescribed by 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) 
  • Medical information that pertains to the participant’s capacity to complete activities of daily living necessary to residing independently or requiring home modifications 
  • 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 
  • Housing relapse management plan 
  • Mental health and primary care provider information for coordination 
  • List of current medications, prescribed by 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 
  • Housing status and address where participant can receive medication 
  • 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 (including any residential restrictions) 
  • The disposition of the participant’s case 
  • Screening and assessment results 
  • Participant’s legal history 
  • Pre-sentence investigation reports when community supervision is the primary plan holder 

Community Supervision 

Lead case planner sends the following information: 

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

Lead case planner receives the following information: 

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

Correctional Agency 

Lead case planner sends the following information: 

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

Lead case planner receives the following information: 

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

Vocational, Employment, and Education Support Services Providers 

Lead case planner sends the following information: 

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

Lead case planner receives the following information: 

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

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 

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Copyright 2024 The Council of State Governments. All Rights Reserved.

This project was supported by Grant No. 2016-MU-BX-K011 and 2020-CZ-BX-K001 awarded by the U.S. Department of Justice’s Office of Justice Programs’ Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Department of Justice’s Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.