Case Study: Developing a Whole-Person Case Management Program for People Exiting the Criminal Justice System

Project Activities

RISE: The First Year

The St. John’s team spent the year building their RISE program. The first six months were spent defining program workflows, developing outreach materials to advertise the new program, training St. John’s clinical staff to help with referrals to the program, and setting up the technology infrastructure to facilitate program activities, including needs assessments and case management.

Project initiation was a little slower than expected, due to delays in the county initiating referrals to St John’s. In addition, the team lost their community health worker and program manager a few months into the project. However, St. John’s was able to hire replacement staff very quickly, thanks in part to help from the main local re-entry services organization.

By March 2018, LA County began referring individuals exiting the criminal justice system to RISE. Within the first two months, the program grew from one caseworker with fewer than 20 clients to two full-time Community Health Workers (CHWs), each with a full caseload of 30 clients. A month after that a third CHW was added and by the end of the program year, the RISE program had four case managers and a supervising LCSW.

A crucial first step in the reentry process is determining health needs and getting clients linked to medical care (e.g., a primary care visit, mental health care, dental care) within the first 10-days of contact. While the goal of WPC-LA is to have eligible individuals exit incarceration with 30-days of medication and a care plan,  this is not always the case. Housing a re-entry case management program in a health center allows CHWs to quickly address these pressing medical needs by making, often same day, direct referrals to St. John’s medical and behavioral health care providers.

“Part of the success as I see it, is just that if a patient with severe schizophrenia is released into [a RISE CHW’s] care, we’re able to connect that person with medication in a timely manner, and prevent relapse. Which is huge!”

– Behavioral Health Services Director

RISE CHWs work closely with patients to create a care plan and to connect them to resources to address the needs identified through initial assessments. CHWs prioritize enrolling patients in benefits like social security or Department of Social Service funding, and providing them with a passport photo and a reduced fare “TAP” card, which allows them unlimited use of public transportation in LA County for $2 a day.

CHWs attend court hearings, make home visits, attend medical visits, enroll and take clients to residential treatment centers for substance abuse treatment, help create resumes, and conduct daily check-ins to monitor patient progress.

Patients who have successfully achieved stabilization goals–employment, housing, connections to family, and connections to medical care and long term supportive services– are discharged from the program. In some cases, patients are ready after two months of case management, but many require more than the three months allotted by WPC-LA.

RISE CHWs have lived experience of incarceration and are highly motivated to help their clients.  Many go above and beyond to provide support, going to court to vouch for the client’s increasing community re-integration, attending program graduations, etc.

The county took notice of the RISE programs early successes and agreed to pay for an additional CHW because they recognized that case coordination within a health care organization was particularly  effective for connecting clients to health care services. In addition, St John’s was also able to obtain funding from another county office (Office of Diversion and Re-entry, or ODR) that wanted to fund similar services. With this new funding, the RISE program was able to assist anyone with history of justice involvement, as well as undocumented individuals.

Next Steps

Based on the success of its first year, St. John’s is planning to expand RISE to provide trans-competent services and services specific to youth. The program team also wants to increase access to substance use treatment and employment opportunities, as these are common needs that they are not currently able to comprehensively address. The team also will continue to look for ways to address clients’ housing needs. Eventually, the team would like to develop a best practices model for integrated intensive case management for the re-entry population that they can share with other FQHCs.

St. John’s Advice for Implementing Social Needs Interventions

• Hire CHWs with lived experience. Formerly incarcerated CHWs bring an invaluable depth of understanding to their work, and can also serve as inspiration to individuals exiting incarceration.

“We tell them, “We’re formerly incarcerated. I’m on parole, I’m on probation. I live in a halfway house.”
They say, “Wow! I would never have thought that.” And, they’re inspired. “I can do this now, too.”
“Yes you can.” – RISE CHW

• When first engaging a new client, focus on building a strong relationship with them. The relationship between the CHW/case manager and the client will often determine whether the engagement is successful or not.
• Develop relationships with other agencies serving the re-entry population. Even if they don’t provide the same services, you’ll learn from their experience.
• Initiate multiple points of entry into the program. RISE CHWs learned fairly quickly that nine out of 10 people who requested services while incarcerated did not follow up post-release. Instead, RISE  identified most clients in the community.
• Connect people to health care, particularly mental health and substance abuse treatment, as soon as possible. Untreated mental health diagnoses or substance abuse disorders will often condemn recently released individuals to a quick return to prison. RISE CHWs make every effort to connect clients with health care services as soon as possible.

“If you don’t have health you can’t get other things done.” – RISE CHW

• It’s important to understand that people exiting incarceration need a lot of help. Be flexible and resourceful in connecting them with relevant resources. At the same time, know when to step back as clients begin to succeed on their own.