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Step 1: Identify the transition plan population

  • Review all screens and assessments gathered at intake.
  • Identify assessed individuals in need of a transition plan, and determine who will receive more intensive interventions based upon a risk triage process.
  • Generate a list of soon-to-be-released individuals to further assist triaging based on risk, needs, and length of stay.

Step 2: Begin to fill out the transition plan

  • Fill out sections of the transition plan using information available from the person's file, inclusive of information obtained while under pretrial supervision.
  • Triage activities dictate who should be seen first and to what extent he or she will receive service and/or further assessment.

Step 3: Prepare the transition plan in consultation with the incarcerated person.

  • A program room, booking area, or other space in the jail should be designated for transition planning conferences.
  • To maximize effectiveness and impact, case managers, counselors, or officers responsible for transition planning meet face-to-face with incarcerated individuals to discuss and form transition plans, including the interventions needed both in jail and after release to the community.
  • If prerelease interventions are required, offer to help the transitioning person apply or sign up.
  • Discuss pre- and post-release interventions and make referrals as indicated by interviews and assessments. Inmates receive a copy of the transition plan with names of the service providers, addresses, telephone numbers, time and date of appointments, and, if possible, public transportation routes to get there.

Step 4: Identify interventions

The case manager, reentry director, counselor, or officer

  • Counsels the incarcerated person on interventions available in the jail and in the community.
  • When feasible, invites a community service provider into the jail to meet face-to-face with the person prior to his or her release to enhance successful linkage and responsivity after release.
  • Works with jail classification and security to coordinate transition plan activities, including housing assignments, program attendance, and referrals to in-custody and community-based services.
  • Develops incentives (e.g., increased visitation, release earlier in the day for those with a plan, improved access to services) to reward the person for starting the in-jail component of the plan and meeting short-term goals.
  • At a minimum, creates a mechanism and timeline to update a transition plan when the incarcerated person completes in-jail programming. The transition plan should act as a “living” document and be reviewed with the incarcerated individual and updated to reflect progress and new goals.

Step 5: Make referrals

The case manager, reentry director, counselor, or officer

  • Communicates with evidence-based community programs and agencies to ensure intervention referrals.
  • Revises transition plans as changes occur.
  • As much as practical, acts as a liaison with community entities to support and invite their presence within the jail. May make presentations and provide information as well as meet potential referrals prior to their release.
  • Schedules referrals for appointments for specific times whenever possible.
  • Notifies local health departments in advance of the release of any person with an infectious disease such as active tuberculosis.

Step 6: Ensure that the transition plan follows the person back to the community

The case manager, reentry director, program staff counselor, or officer

  • Determines a comprehensive process for having transition plans follow people from jail to the community.
  • Ensures that transition plans are written in a format that allows them to also be used by probation officers and service providers upon release.
  • Ensures that all individuals with mental health issues leave with medication and an appointment at their local health clinic.
  • Contacts all individuals with high risk and/or high needs within the first week after release to determine if they have kept appointments, maintained prosocial contacts, complied with treatment or probation directives, and maintained employment. Provides any additional help or referral that might be necessary.