Challenges
The subject matter experts named addressing mental health and substance use challenges as one of the highest priorities and most challenging issue areas related to transition from jail to the community. Jails have long held people who experience mental illness and substance use disorders (including problematic use of alcohol), and jails have never served as an optimal setting to address these issues. In the view of the expert advisors, these longstanding jail reentry challenges have intensified in recent years, with more individuals entering the jail sicker and waiting longer to transfer to state hospitals for competency restoration. They described an increase in individuals with mental health conditions in custody and an increased prevalence of overdoses.
These trends make quick identification and successful management of behavioral health conditions a greater proportion of the work of jail management generally and reentry preparation specifically. Experts raised the need to address co-occurring needs with mental health and substance abuse and the need to attend to other medical issues that can arise from lack of self-care and engagement in medical treatment arising from mental health and substance use issues. Timely identification of whether someone has a substance abuse disorder can be extremely consequential, as substance abuse disorders significantly increase suicidal ideation, attempts, and death (Rizk et al 2021). It is estimated that almost two-thirds of sentenced jail inmates meet the criteria for drug dependence or abuse (Bronson et al. 2017). Jail mortality rose by 11 percent between 2000 and 2019, with suicide as the leading single cause of death in 2019 (Carson 2021). One expert described the direct link between withdrawal symptoms and the urge to complete suicide and noted that this connection may not be documented officially and therefore underappreciated in importance when data on suicides in jail are examined.
When treatment needs are correctly identified, uncertainty around length of stay presents a barrier to delivering treatment and interventions. For example, jails may obtain a 30-day supply of medications for someone who ends up released after one or two days, with remaining medications getting returned or thrown out because the jail may not have space to store them. Jails may also lack options for some of the evidence-based responses to common mental health and substance use dependency issues. A recent study including over 1,000 jails found that fewer than half of these jails offered medications for opioid use disorder (Flanagan Balawajder et al. 2024).
- Care administration and management issues in the jail can present barriers to addressing behavioral health needs. Many jails contract for healthcare and those contracts may not follow consistent best practice for what should be covered. A lack of coordination between behavioral health and other medical care staff in the jail can generate further complications, raising issues around multiple assessments and case managers who are tied to different systems and specialties. Some subject matter experts also raised concerns regarding consent decrees, court-enforced settlements agreed upon by all parties that can result from court cases regarding unjust patterns in correctional settings. Consent decrees can be used to address mental health crises in jails but may require measures such as allocation of in-custody staffing resources that are difficult and costly to implement and maintain.
- The subject matter experts also identified staffing shortages as a major challenge in the provision of behavioral health services. While most jails offer access to behavioral health providers, the time and services of these providers is often limited (Rosen et al. 2024). One reason for the shortage of mental health professionals is that many professionals choose to work in other settings. Some hesitations for working in correctional settings may include misconceptions surrounding stigma, safety concerns, and lack of teaching/research opportunities (Morris and West 2020). In recent years the inability for staff to telework in correctional settings as they can in other clinical community programs has contributed to difficulties in filling these positions. In addition to staffing shortages among health care professionals in jails, shortages of security staff make jail processes that are necessary for treatment access, such as med lines to obtain regular medication or movement generally, more difficult to carry out. Further, behavioral health provider capacity on the community side is often limited, especially in smaller and more rural communities, challenging access to needed care after release.
Opportunities
To improve reentry outcomes, experts recommend the use of behavioral health screening tools to make clinical assessment of needs during jail booking and establish a diagnosis for the individual. Those who are diagnosed should receive both a transition plan and referral to a community-based behavioral health treatment provider in addition to the treatment they receive while in jail custody. The transition plan and community referrals are critical because short and unpredictable stays in jail limit the ability of jails to reliably do more than assess and stabilize individuals with behavioral health needs. For medications, individuals should receive prescriptions for any behavioral healthcare-related medication in addition to a short supply of the medication for the initial period of reentry. Jails can also benefit from relying on resources such as the Guidelines for Managing Substance Withdrawal in Jails recently developed by the U.S. Department of Justice (Bureau of Justice Assistance and National Institute of Corrections 2023).
The provision of medications for opioid use disorder (MOUD) can improve behavioral health outcomes for those in custody, with Medicaid expansion supporting post-release access to services in the states that have adopted it. As an example, the Camden County Correctional Facility in New Jersey began offering MOUD in 2018, and the program has grown to offer it to over 1,000 individuals through a partnership with the New Jersey Division of Mental Health and Addiction Services. An analysis of Camden County’s program found that program participants were 41.2% less likely to experience an overdose within 180 days of a jail release and 38.5% less likely to experience an overdose within 365 days (Wiest, Truchil and Wang 2023). The analysis did not assess the effect on recidivism. In Middlesex County, Massachusetts, MOUD offerings combine medication with counseling/programming, and the program has promising recidivism outcomes despite serving a high-risk population (Middlesex Sheriff’s Office 2018). However, the benefits come with operational challenges mitigating diversion and abuse of the medication.
Medicaid expansion allowable under the Affordable Care Act has meant that almost everyone returning from jail in states adopting the expansion is Medicaid-eligible. Successfully enrolling Medicaid-eligible individuals in the jail reentry population provides a funding source for needed care in the community, although there are steps beyond enrollment that the reentry partners need to coordinate because transition for appointments and medication is not seamless. Recently approved section 1115 Medicaid waivers allow states to provide Medicaid-funded health services to people held in jails for up to 90 days prior to release from incarceration (Hinton, Pillai and Diana 2024). As of September 2024, 11 states can offer services to Medicaid-eligible individuals who are incarcerated, and 13 states are pending (ibid.). Though these Medicaid waivers provide support for those who are incarcerated, one expert noted that these waivers require additional coordination. The first implementation states are early in that process at the time of this writing, and the implementation experience needs to be monitored to learn how to maximize its potential to support jail reentry.
The subject matter experts raised many ways that local capacity could be supplemented to meet reentry needs related to behavioral health. One expert suggested looking at contracts to determine how to increase transportation access for people with behavioral health needs, since many struggle to get to their substance abuse treatment appointments. Montgomery County, Maryland, uses a community reentry ID that provides free bus transportation for sixty days. Another expert mentioned that their jail medical provider could not prioritize substance use treatment and counseling, so they hired a separate vendor to provide those services. Jails and jail reentry partnerships can also consider tapping into community health centers to supplement treatment and intervention capacity.
On coordinating with jail staff and community providers, experts highlighted the role of community navigators, who in their community work specifically with MOUD clients to connect them with community services prior to leaving the jail. One panel member described the process in their community: “Navigators call the pharmacy to let them know the script is coming, they work with individuals to identify a pharmacy they can use after they leave, and this all happens while the individual is in jail so it is set up when they leave.” These navigators make the referral and work with hospitals and agencies to set up the appointments. The jail also created a prescription hotline to assist anyone who encounters problems obtaining their prescription. Since community health workers can be reimbursed by Medicaid, they’re a low-cost source of capacity for jail administration. Community health workers can build connections through contacting mental health clinics and housing providers to facilitate immediate support.