At Intercept 4, people plan for and transition from jail or prison back into the community. Intercept 4 Overview Provides transition planning and support to people with mental and substance use disorders who are returning back to the community after incarceration in jail or prison. Ensures people have workable plans in place to provide seamless access to medication, treatment, housing, health care coverage, and services from the moment of release and throughout their reentry. Key Elements for Diversion at Intercept 4 Transition planning by the jail or in-reach providers improves reentry outcomes by shaping services around a person’s needs before they are released. Planning for reentry should begin at intake and continue during the person’s incarceration; it should involve providers and resources across criminal justice, behavioral health, and physical health care systems. Examples: Risk-Needs-Responsivity (RNR) Simulation Tool, Collaborative Comprehensive Case Plans (CC Case Plans) Medication and prescription access upon release from jail or prison. When they are released, people should have enough medications and prescriptions to allow them to follow their treatment plans and avoid relapse while waiting to see their community-based medical provider. Warm hand-offs from corrections to providers increases engagement in services. People who are picked up upon release and provided transportation directly to services often see more ideal outcomes compared to people who are simply released to the streets. Ideally, the community-based worker doing the pick-up would already have provided in-reach services throughout Intercept 3, built relationships, and become a trusted partner for the reentry process. Benefits and health care coverage immediately following or upon release. States are encouraged to suspend rather than end Medicaid coverage. This allows people coming back to the community to quickly access important treatment services and medications. Where possible, paperwork to start or restart benefits and/or health care coverage should be done before release. That way, these essential resources are available to people with mental and substance use disorders during their transition back to the community. Examples: SSI/SSDI Outreach, Access, and Recovery (SOAR); Medicaid and Medicare: An Overview; Health Insurance Marketplace Peer support services. Individuals who have gone through the transition from jail or prison to the community can provide valuable peer support. They can help people plan for reentry, identify safe housing, and learn about triggers or issues that could lead back to the justice system. Peer staff may be employed by the jail or by in-reach providers to deliver transition planning services. Reentry coalition participation. Many communities have a group that meets and plans for supporting people reentering the community from prison or jail. Partners from criminal justice, behavioral health, and all types of supportive services should be involved. These partners can help coordinate the processes and resources available to people with mental and substance use disorders as they plan their transition. Local Examples at Intercept 4 The Fortune Society (NY) This program’s mission is to support successful reentry from incarceration and promote alternatives to incarceration, strengthening the fabric of communities. A comprehensive “one-stop shop” model of reentry services addresses the complex and overlapping needs of clients. This includes substance use treatment, mental health treatment, Alternatives to Incarceration (ATI), Benefits Application Assistance (Single Stop), creative arts, education, employment services, family services, food and nutrition, health services, housing, and Prepare for Release (I-CAN). New York State Health Home Program (NY) This pilot program connects previously incarcerated people to a health home upon reentry. The health home provides primary health care to address chronic illness and mental and substance use disorders. Before they get out of jail or prison, clients are linked with a care manager who coordinates their care through a network of providers after release. People Achieving Change Together (P.A.C.T.) Young Offender Unit (MA) This is a specialized unit at the Middlesex Jail and House of Correction. In partnership with a local reentry nonprofit, United Teen Equality Center, it provides reentry support services for young adults serving their sentences. Mental Health Association Nebraska Honu Home (NE) This peer-operated respite center is available to people with mental health or substance use disorders who are just coming out of a state correctional facility or within the 18 months after their release. The center provides transition support and supported employment services, is staffed by peers, and has a warm line available 24 hours a day, 7 days a week. Limited, temporary housing is also available with lengths of stay based on the person’s needs.