While being in jail can be tough, leaving jail presents its own challenges. For jail releasees with mental health diagnoses who lack housing, challenges at discharge can be huge and can include substantial barriers to accessing adequate community-based services. For many, jails may be the only place providing regular access to essential health treatment. Upon release, both health services and medication regimens often abruptly stop with little or no follow up care. Access to sufficient support and services upon release can be a critical component of successful reentry for many offenders, even helping to reduce rates of recidivism.
In our recent article, Integrated Primary and Behavioral Health Care in Patient-Centered Medical Homes for Jail Releasees with Mental Illness (by Mary Lehman Held, Carlie Ann Brown, Lynda E. Frost, J. Scott Hickey, and David S. Buck), we examine an integrated health program designed specifically to meet the needs of releasees with mental health challenges and who lack housing. Research shows rates of serious mental illness to be 14.5% among male detainees and 31% for female detainees, as compared to 5.4% of the general population. Additionally, oftentimes jails are the only, or primary, source of behavioral health treatment for this population. While jails have a legal obligation to treat health conditions for detainees, this obligation ends at the time of release so that jails are not obligated to link releasees with physical or behavioral health treatment on reentry. Without adequate health treatment, especially for mental illness or substance abuse, releasees risk ending up in a crisis state that results in going to an emergency center or back to jail. The risk is even greater for the 17% of releasees with mental health challenges who also lack housing.
Healthcare for the Homeless – Houston (HHH) began in 2001 and operates three health clinics to provide free integrated health care to individuals who are homeless in Houston, Texas. It established the Jail Inreach Project in 2006 to offer free integrated health services specifically for jail releasees with mental health challenges who lack housing. The Jail Inreach Project has three aims:
- To prevent the rapid deterioration of mental health status on release from jail
- To reduce rearrest rates and combat the rapid cycling of homeless individuals with mental illness through the Harris County Jail
- To develop a more coordinated system of care that improves access to needed primary and behavioral health services
In order to facilitate access to treatment for this population, the Jail Inreach Project takes steps to overcome traditional barriers experienced by offenders at release, such as lack of knowledge of available services, transportation to services, and continuity of care. Once an individual is referred to the Jail Inreach Project, a case manager meets with the detainee while still in jail to explain the services and offer a unique release option. Release from jails typically occurs during the early morning hours while it is still dark outside and businesses are closed. The Jail Inreach Project has arranged with the Harris County Jail to offer a day time release in which the case manager is present to walk with individuals from the jail to the nearest HHH clinic. This step not only eases the reentry process, but also helps to facilitate trust and relationship building while ensuring that participants show up for their appointments. All Jail Inreach Project participants have access to the full range of services offered by HHH. These services may include any or all of the following: physical and behavioral health care, medical case management, individual and group counseling, psychiatry (including telepsychiatry), chaplaincy (or pastoral counseling), and substance abuse counseling, as well as dental and ancillary services. Treatment is designed to meet each participant’s individualized needs, so case managers coordinate with other agencies to locate services that are not provided by HHH.
Buck, Brown, and Hickey (2011) conducted a preliminary evaluation of the Jail Inreach Project in 2009 and included participants from January 2007 through June 2009. This analysis began with a review of the records of all participants who had been engaged in the Jail Inreach Project services for at least one year. These records were matched with the Harris County Jail arrest records, and then narrowed using specified inclusion criteria for program participants.
We applied the same methodology for our study while examining a broader time span from January 2007 through April 14 2011. This produced a sample size of 207 participants with 105 females (50.7%) and 102 males (49.3%). The majority (87%) was diagnosed with substance abuse, 38% with affective disorders (including depression, bipolar disorder, and other mood disturbances), and about 19% with schizophrenia or other psychoses.
We used analyses of variance to examine four dependent measures: (1) the total average annual bookings into the Harris County Jail, (2) the total number of charges per year, (3) the average number of felonies per year, and (4) the average number of misdemeanors per year. For comparative purposes, we divided the study period into pre-engagement and post-engagement phases. Pre-engagement included the time frame extending backward one year from the arrest that corresponded with participation in the Jail Inreach Project while the post-engagement period extended one year out from the date of release from jail. Finally, we were interested in examining the impact by age, so constructed an age-group factor by median split at the median age of 39.32 years to compare older and younger participants.
Our findings show that participation in the Jail Inreach Project is positive for participants and jails alike. We found that total average annual bookings per person into the Harris County Jail dropped by 57%, the total number of felonies by 71% and misdemeanors by nearly 50%. The total number of days spent in jail per person per year was reduced by 28.4%. A significant difference by age group was not present. What was significant for age was the interaction effects for both number of bookings and number of charges, so that older participants improved more from the program.
These findings are also relevant in the current policy environment. The Patient Protection and Affordable Care Act (PPACA), which was passed in March 2010, emphasizes facilitating access to primary care services, identifying Patient-Centered Medical Homes as one way to meet high health needs of individuals. The Jail Inreach Project is an example of an integrated health care Patient-Centered Medical Home model that is designed specifically for releasees from jail.
An example of one participant (“Nikki”) who engaged in the Jail Inreach Project helps to highlight aspects of the program that are beneficial for the targeted population. At about 50 years old, Nikki has been diagnosed with HIV, bipolar disorder, and substance use. Additionally, she has repeatedly been detained in jail as a result of addiction and prostitution, engaging in a cycle of arrest, spending a few months in jail, and then returning to her former environment, substance abuse, and prostitution. After being referred to the Jail Inreach Project, a case manager met with Nikki while she was still in jail.
Nikki explained that while she would like to break this cycle that she was in, she was not sure how to do so. After learning about the Jail Inreach Project from the case manager, she agreed both to participate in the program and to the special daytime release option. Therefore, on her day of release, Nikki’s case manager met her outside of the jail to walk with her to the HHH clinic where her physical health, behavioral health, and psychosocial needs were assessed. An immediate need that was quickly met was adequate clothing for Nikki, as she had been arrested in the summer and released on a cold winter day with only shorts and a t-shirt. She then was linked with transitional housing and specialized treatment services for individuals diagnosed with HIV. The extent of services that the Jail Inreach Project was able to either provide or coordinate for Nikki allowed her to live in a safe environment while engaging in treatment for her addiction, bipolar disorder, and HIV diagnoses. Providing an individualized service plan that comprehensively met Nikki’s needs enabled her to successfully transition from jail back into the community.
Unfortunately, Nikki’s situation is not unusual, as there is a huge unmet need for both continuity of comprehensive health and psychosocial services for individuals released from jail. Studying programs for individuals with mental health challenges who lack housing is especially critical in light of this unmet need, as well as some of the problems visible in the United States today, including a growing jail population, overcrowding of jails, and high rates of recidivism. Based on our findings in this study, the Jail Inreach Project is successfully changing lives and reducing the burdens on the Harris County Jail.